HEALTH PLANNING IN MAHARASHTRA STATE

CHAPTER - III HEALTH PLANNING IN MAHARASHTRA STATE 3.1 INTORDUCTION Located in the north centre of peninsula of India, with the command of Arabian Sea, Marathi speaker occupied, ranking in second position in case of population (census 2001) and ranking in third position in case of area Maharashtra is the leading state of the Indian Republic. According to census 2001, Maharashtra population was 9.69 crore, the percentage of urban population in the State was 42.6 and Maharashtra was second most urbanised state after Tamil Nadu. At the same time out total of the population, 57.6 per cent people were residing in 43722 villages. The present chapter deals with the constitutional provision of public health expenditure, health infrastructure in the state and its impact on health indicators especially with the reference of rural area of Maharashtra State. 3.2 PUBLIC HEALTH SYSTEM AT STATE GOVERNMENT LEVEL A State Health Department, being one degree nearer the individual citizen, has greater authority than any other jurisdiction and a more intimate relation to local health departments that the Central government. 1 According to Constitution of India health is the subject of the state government. The Directive Principles of the Indian Constitution enunciate that, the state shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties

72 (Article 47). After the making health policy for health by central government, it is the responsibility of the state government to execute the policy. In this direction the implementation, surveillance and providing technical assistance at local level are functions to be accomplished by the state governments. To provide medical services and public health facilities to the people are the main functions of the state governments, in it includes the Hospitals, pharmaceuticals and similar services. Due to decentralisation of democracy, Zila Parishad provides all kinds of health services to the rural area, while in the urban area it is the responsibility of Municipal Corporation. For the convenience of study the public health scheme is divided into two parts, 1. Environmental Health Services and 2. Personal Health services. The local government performs these functions on behalf of state governments. 1. Environmental Health Services In order to control and eradicate epidemics and other diseases, sanitation services played a vital role. The state government did not perform this kind of work directly, however, the local governments have to accomplish this work. Environmental Health Services include the services such as public sanitation services. The state government provides medical and health, guidance and surveillance related, help to all local governments. 2. Personal Health Services The purpose of environmental health is to bring about conditions that will promote health and prevent diseases. The concept of environment includes water supply, disposal of wastes, and housing, personal hygiene and disease control. Personal health services refer to the health services where people benefited individually by the health services. It includes the Maternal and Child Health Services, School Health Programmes, etc. At the same time it includes the hospitals, doctors, nurses and paramedical staff who treat the patients. In case of rural area the state government deputed the functions like environmental health services to the Village Panchyat, while the personal health services were deputed to the Zila Parishad.

73 3.3 HEALTH ADMINISTRATION IN THE MAHARASHTRA STATE In all States, the management sector comprises of the State Ministry of Health and A Director of Health. The State Health Ministry is headed by the Minister of Health and Family Welfare who is elected by the people. The Health Secretary is usually a senior I.A.S. Officer. The Health Ministry deals mainly with administration, and policy decisions, approval of plans, finance and Budget. The Health Directorate is headed by the Directorate of Health Services. He is the chief technical adviser to the State Government on health matters. The Director of Health Services has several assistants who are MCH, Family Welfare, Nutrition, Communicable Diseases and Health Education. Functions of the State Health Director The functions of the State Health Director are given below: 1. Formulating the plan for health services, directing the approved health programmes and evaluating them. 2. Rendering preventive services and curative health services 3. Supervision of PHCs through the organisation of District Health Services 4. Control of milk and food sanitation and adulteration 5. Execution of central government health programmes e.g. MCH and Family Welfare 6. Recruitment of personnel for rural health services 7. Training of P.H. Nurses, Sanitarians, Health Assistants and Health Workers, (former ANMs). 8. Promotion of health education and nutrition programmes 9. Collection of vital statistics 10. Co-ordination of health with other Ministries of the State, with the Central Health Ministry and with voluntary agencies.

74 3.4 HEALTH ORGANISATION Medical Services in Maharashtra States was organised in the beginning of the 19 th century. The year 1942 was considered an important landmark regarding more recent origin of Health Services. Till recently the Medical and Public Health Department were functioning independently of each other at the State, Divisional and District levels. The Medical Department was under the Surgeon General and the Public health Department worked under the Director of Public Health. The Medical Department looked after curative medical care as well as Medical Education including training of medical and para-medical medical personnel and the Public Health Department was in-charge of preventive health services and family planning. Thus the responsibility for Medical Care and Education on the one hand and that for Medical Care in rural areas, control of communicable diseases, maternal and child health education on the other, was clearly divided into two separate and independent compartments. To achieve proper coordination in total health care and to avoid duplication of efforts and overlapping of work an integration of these two services became necessary. Government took steps in this direction and from 1970, 1 the post of Director of Public Health was abolished and the post of Director of Health Services was created with Headquarters at Bombay to control both Medical and Public Health Services in the State excluding Medical Education and Research. Similarly the post of Surgeon General was abolished and instead the post of Director of Medical Education and Research was created. The Director of Health Services is assisted by five Joint Directors of Health Services, two being stationed at Bombay and the other three at Pune. Out of the three Joint Directors at Pune one looks exclusively after Family Planning, Maternal and Child Health and School health work. Further, the Deputy Directors of Medical Services and Deputy Directors of Public Health Services were changed to Deputy Directors of Health Services (Bombay). Besides the Joint Directors of Health Services, there is a Deputy Director of Health Services. The whole State, at the Divisional Level, has been divided

75 into Seven Circles for convenience of administration and each Circle is incharge of a Deputy Director of Health Services. All the health related functions are performed by the minister of health. These functions are performed by the Urban Development Minister through the local governments instead of Minister of Health. In case of urban area Urban Development Minister surveys the work of Municipal Corporation and Corporation. There is also a Health Officer in the corporation to carry out the health programmes. The Ministry of Health provides technical guidance to them, but cannot interfere in the work or directly supervise them. This is same in the case of rural area. The health officer of the Zila Parishad and their assistant health officer carry out the health programmes through the health staff. HEALTH BODIES 3.4.1 STATE HEALTH MISSION Recognizing the importance of health in the process of economic and social development and improving the quality of life of our citizen particularly of poor and vulnerable section of the population the central government has resolved to launch the National Rural Health Mission to carry out the necessary architectural correction in the basic health care delivery system. The mission adopts a synergic approach relating health to the determinant of good health viz. segment of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian system of medicines to facilitate health care. The plan of action includes increasing public expenditure on health, reducing regional imbalances in health infrastructure, pooling resources integration of organizational structure, optimization of health management decentralization of district management of health programs, community participation, ownership of assets induction of management and financial personnel into the district health system and operationalization of community health center into functional hospital meeting Indian public health standard in each block of the state.

76 The implementation of the National Rural Health Mission with architectural correction was under active consideration of the Government of Maharashtra. In this regard Government of Maharashtra has passed the following resolution: Resolution: Government is pleased to constitute a State Health Mission on the lines of the National Rural Health Mission. Composition of mission is as follows: Hon. Chief Minister is the Chairperson, Hon. Dy. Chief Minister is Co. chairperson, and Hon. Minister Public Health is Dy. Chairman. Hon. Additional Chief Secretary is the member secretary. The State Health Mission meets at least once in every 6 months. The business of the mission is as follow: Providing health system oversight Consideration of policy matters related with health sector (including determinants of good health) review of progress in implementation of NRHM. Inter sectoral coordination Advocacy measures required to promote NRHM visibility. The state health mission was constituted on15 th October 2005 3.4.2 STATE HEALTH SOCEITY The state health society was constituted on 24th October 2005. State health society comprises of governing body and executive committee, which serves in an additional managerial and technical capacity to the dept of public health for effective implementation of NRHM / RCH II. a) The governing body has Chief Secretary as the Chairperson, Principal Secretary Planning Department as the co-chair person and Additional Chief Secretary Health as the Vice-Chairperson. Mission Director is the member secretary of the governing body. The committee has also nominated non

77 official members and representatives from development partners as members. The business of the governing body is as follows : Approval /endorsement of annual state action plan for the NRHM. Consideration of proposals for institutional reforms in health and family welfare sector. Review of implementation of annual action plan Inter sector coordination: all NRHM related sectors and beyond (e.g. administrative reforms across the state) Status of follow up action on decision of the State Health Mission. Coordination with NGOs / donors / other agencies / organizations. b) The executive body has Additional Chief Secretary Health as the Chairperson, Commissioner Family Welfare as the Co-chair Person and Director Health Services as the Vice-Chairperson. Mission Director is the member secretary of the executive body. These committee has also nominated non official members and representative from development partners as members. The business of the executive body is as follows: Detailed implementation and expenditure review Approval of proposals from district and other implementing agencies / district action plan Execution of the approved state action plan, including release of funds for programmes at state level as per annual action plan Release of funds to the district health society Finalization of working arrangement for intra sectoral and inter-sectoral coordination. Follow up action on decision of the governing body. After sanction of state action plan by the governing body of the State Health Society and of district plans by executive committee funds are released through joint signature of authorized signatories.

78 3.4.3 DISTRICT HEALTH MISSION On the lines of State Health Mission every district has a District Health Mission headed by the Chairperson Zila Parishad and District Collector as the Co-chairperson and Chief Executive Officer as the Mission Director. To support the District Health Mission every district has a District Integrated Health and Family Welfare Society and all the existing societies are merged in it. 3.5 SOME IMPORTANT HEALTH PROGRAMMES RUN BY PUBLIC HEALTH CARE SYSTEM IN MAHARASHTRA STATE To cure the disease and heal the injuries and give relief from pains to the patients is the first responsibility of every public health center. At the same time, execution of the various health programs deputed by the Central and State Government is also the responsibility of public health centers. Hitherto several measures have been undertaken by the Central and State Government to improve the health of the people. However, The Central Government cannot maintain an organization reaching every individual and protecting every community with adequate service. Not only would such an organization fail; but in this country of local government such a situation would not and should not be tolerated. It is but slightly less absurd to expect a state. 3 State Government has successfully implemented these programs through the public health care system. A brief account of these programs which are currently in operation is given below : 3.5.1 FAMILY WELFARE The family welfare program is being implemented in the State since 1957. It is a high priority program. To stabilize population and improve quality of life is the main objective of this program. Sterilization program under family welfare is well established in the state. During the 2008-09 there were 238.5

79 thousand sterilization operations performed with different sterilization methods in the State, however the target (450 thousand) was not achieved. 4 3.5.2 REPRODUCTIVE AND CHILD HEALTH PROGRAMME (RCH) With an objective to improve the performance of family welfare in reducing maternal and infant mortality, unwanted pregnancies and thus lead to population stabilization the Second Phase of Reproductive and Child Health (RCH-II) was launched on 1 st April, 2005 for period of five year. During the 2008-09 Rs. 224.64 crore were sanctioned and an expenditure 0of Rs. 177.16 crore was incurred under the RCH. 5 3.5.3 JANANI SURAKSHA YOJANA (JSY) The Janani Suraksha Yojana (JSY) is a modified scheme of National Maternal Benefit Scheme. JSY is being implemented in the State since 2005-06 with objective of reducing maternal and neo-natal mortality by promoting institutional deliveries among the poor pregnant women. Under the scheme, for urban area, Rs. 600 and for rural area Rs. 700 is given to the beneficiary after delivery in the institution within seven days while for home delivery an amount of Rs. 500 is given to the beneficiaries having up to two living children. During the 2008-09 Rs. 23.81 crore expenditure was incurred under the same scheme. 6 3.5.4 NATIONAL RURAL HEALTH MISSION (NRHM) Recognizing the importance of health in the process of economic and social development and to improve the quality of life of its citizens National Rural Health Mission (NRHM) was launched on 12 th April, 2005. The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care and bridging the gap between rural health care through creation of a cadre of Accredited Social Health Activist (ASHA). The mission will be an instrument to integrate multiple vertical programs along with their funds at the district level. The programs to be integrated are existing

80 programs of health and family welfare including RCH-II; National Vector Borne Disease Control Programs against malaria, filaria, kala azar, dengue fever, etc.; National Leprosy Irradiation Program, National Tuberculosis Program, National Program for Control of Blindness, Iodine Deficiency Disorder Control Program and Integrated Disease Surveillance Project. The NRHM also attempts to make effective integration of health determinants like sanitation and hygiene, nutrition and safe drinking water. 7 3.5.5 SCHOOL HEALTH PROGRAM Under this programme students from I to IV standard are examined every year and are provided free of cost medical services. For needy students even major operations like cardiac surgeries are provided free of cost. During 2008-09 about 108.02 lakh students from 79543 schools throughout the State were examined and primary treatment was given for illness and referral services were provided for major illness. 8 3.5.6 UNIVERSAL IMMUNIZATION Universal Immunization Program was started in 1985-86 to achieve 100 per cent immunization and to reduce mortality and morbidity among infant and young children due to vaccine preventable diseases such as Tuberculosis (T.B.), diphtheria, whooping cough, tetanus, polio, measles. The immunization programs include the vaccination like BCG, DPT, Polio, Hib, Measles, DT, Tetanus etc. Over the period, coverage of different vaccination is increasing but it has yet to reach the cent per cent target. During 2008-09 the State Government has incurred an expenditure of Rs. 11.26 crore under this head. 9 3.5.7 PULSE POLIO PROGRAM The Pulse Polio Immunization Program is the largest ever conducted program of immunization in every country across the world. In India, with intension to eradicate polio disease from all over the country Pulse Polio

81 Immunization Program was started on 9 th December 1995. Maharashtra State has made good progress in controlling the spread of wild polio virus in the State. Under this programme, all children below 5 years of age are given dose of oral polio vaccine. During 2008-09 an expenditure of Rs. 26.64 crore was incurred for the program. 3.5.8 NATIONAL AIDS CONTROL PROGRAM (NACP) Looking at the gravity of HIV infections in the country, Government of India started National AIDS Control Program (NACP) in the year 1987. It is a 100 per cent centrally sponsored scheme implemented in the State through Maharashtra State AIDs Control Society (MSACS). Monitoring HIV supervisors, controlling STDs, controlling the spread of HIV infection from mother to child, condom promotion, provision of antiretroviral treatment, school aids education, AIDS telephone helpline, etc. are the major features of NACP. 10 3.5.9 NATIONAL VECTOR BORN DISEASE PROGRAM National Vector Born Disease Control Program (NVBDCP) is being implemented for prevention and control of vector borne disease like Malaria, Lymphatic Filariasis, Japanese Encephalitis (JE), Dengue, Chikungunya and Chandipura, etc. In 2008-09, there were 165 people died due to malaria, 21 people died due to dengue and 16 people died due to chandipura disease. 3.5.10 INFLUENZA A (H1N1) PANDAMIC (SWINE FLU) With the time medical science has achieved a great success in control and eradication of various endemic and pandemic chronic diseases. However, with the changing situation diseases also changed, some new diseases raising their heads in society, the H1N1 disease also being one of them. During 2009, the State faced a serious problem due to Influenza A (H1N1) popularly known as a Swine Flu. It is an air borne disease, which spreads rapidly in the

82 community through coughing and sneezing of positive patients. So far, about 4606 people have been found H1N1 positive, 224 people have died due to this dangerous disease. Pune region was found to be the most affected area in the state where 123 deaths occurred due to swine flu in till 2009. The State Government accepted different measures to prevent spread of swine flu. The measures taken by the State are as follow: Medical teams are deployed at air ports, railways stations, harbors and bus stations to screen international passengers and domestic passengers for influenza like illness. To isolate and treat suspected and affected cases, the Government has started Identified Isolation Wards (IIWs) in every district. Private hospitals have also been involved in this activity. Free facility of laboratory diagnosis of H1N1 is provided at National Institute of virology, Pune and Haffkine Institute, Mumbai. 142 members Rapid Response Team (RRT) have been trained to tackle swine flu Sufficient quantity of Temiflu capsule, syrups, masks, hand sanitizers are provided. Up to the end of November 2009, 107 IIWs and 1501 screening centers are available in the State, 0.79 lakh suspected cases have been given Temiflu. Along with these health programs Jeevandayi Arogya Yojana (JAY) providing financial assistance to BPL families for major surgeries of organs, Navsanjivani Yojana to reduce maternal mortality and infant mortality in tribal areas, Matrutva Anudan Yojana (MAY) to provide health services to pregnant women, antenatal care (ANC) Registration, regular health check up and to provide required medicine to women in tribal area have been implemented in the State.

83 3.6 EXPENDITURE ON PUBLIC HEALTH OF MAHARASHTRA STATE There has been no standard definition of health care expenditure. It is a well known fact that the health status of the people is influenced by a large number of factors and is a function of medical care, income, education, sex, marital status, and environmental pollution etc. Given too many factors influencing health it becomes difficult to define what items constitute health care spending and what truly reflects health care expenditure. However, expert on health economics have explicitly mentioned that all that activities that primarily and significantly contribute for improving health status of the people should be included and others should be judged on their merit. (Berman Peter,1994) As we know medical and health comes under the State list. Under the revenue expenditure head developmental expenditure of state government incurred a huge amount on the social services. Expenditure on social services includes the heads such as education, sports, cultural, expenditure on health and family welfare, water supply, sanitation, information and broadcasting, SCs/STs and OBCs welfare scheme, social welfare, nutrition, etc. An expenditure on health and family welfare is one of the most significant elements of expenditure on social services. In order to increase health status the state government has spent a huge fund under the head of health and family welfare. However, India s social services were used relatively little by the poor. The health of the poor has improved but not as a whole. Physical access to health services has improved but inequalities exist because of biases in locating facilities. 11 Social services policies are not comprehensive enough and the quality of services is low. The bureaucracy is inadequate to reach the poor. Existing capacity and resources are inadequate, particularly for education and health. 12

84 Year Table no. 3.1 Growth Profile of Expenditure of Maharashtra State on Public Health Total Exp. % of 10 to 2 Total Rev. Exp. % of 10 to 4 Total Dev. Exp. % of 10 to 6 Exp on Social Services (Rs. in crore) % of 10 to 8 Exp. on H&FW 1 2 3 4 5 6 7 8 9 10 1980-81 3094 5.24 1917 8.45 1435 11.29 678 23.89 162 1990-91 10773 4.43 8754 5.45 5616 8.49 3024 15.77 477 2000-01 48160 3.31 37401 4.26 22699 7.03 14351 11.11 1595 2001-02 54911 3.25 38281 4.66 20551 8.68 14137 12.62 1784 2002-03 61215 2.71 40474 4.09 22527 7.35 14228 11.64 1656 2003-04 70356 2.51 42680 4.14 22860 7.73 15990 11.06 1768 2004-05 76206 2.48 51047 3.7 28776 6.57 17549 10.78 1891 2005-06 72362 2.94 52280 4.06 30583 6.95 19917 10.66 2124 2006-07 78506 2.87 61385 3.67 36279 6.21 23559 9.57 2254 2007-08 82194 3.28 64780 4.16 40934 6.58 26773 10.07 2695 2008-09 RE 103461 3.05 78607 4.01 51620 6.11 32752 9.64 3156 2009-10 BE 122762 2.58 96184 3.29 61076 5.19 30255 10.47 3167 G.R. (1980-81 to 1990-91) G.R. (1990-91 to 1900-2001) G.R. (2000-01 to 2009-10) 3.4819 0.8454 4.5665 0.645 3.9136 0.752 4.4602 0.6601 2.9444 4.47043 0.7471 4.2724 0.7816 4.04184 0.8280 4.7457 0.7045 3.3438 2.549 0.7795 2.5717 0.7723 2.6907 0.7383 2.1082 0.9424 1.9856 C.G.R. 9.256-0.701 10.855-2.135 12.741-3.771 10.882-2.152 8.4904 Note : C.G.R. is calculated for the year of 2000-01 to 2009-10. Source : Economic Survey of Maharashtra of various years.

85 Observations Table no. 3.1 shows the growth in expenditure on public health and family welfare of Maharashtra State and its percentage to total expenditure, total revenue expenditure, development expenditure and expenditure on social services. The following things were found. 1. Expenditure on health and family welfare increased from 162 crore to 477 crore during 1980-81 to 1990-91 with the growth rate of 2.94, It reached 1595 crore during 2000-01 with growth rate of 3.43. In 2008-10 the expenditure on health and family welfare increased to 3067 crore with growth rate of 1.9. It means, in last 10 years the growth rate of expenditure on health and family welfare had declined 2. The percentage of health and family welfare to total expenditure was declined from 5.24 per cent in 1980-81 to 4.43 per cent 1990-91, 3.31 per cent in 2000-01 and 2.58 per cent in 2008-09. 3. The percentage of health and family welfare to total revenue expenditure declined from 8.45 per cent in 1980-81 to 5.45 per cent 1990-91, 4.26 per cent in 2000-01 and 3.29 per cent in 2008-09. 4. The percentage of health and family welfare to developmental expenditure declined from 11.29 per cent in 1980-81 to 8.49 per cent 1990-91, 7.03 per cent in 2000-01 and 5.29 per cent in 2008-09. 5. The percentage of health and family welfare to developmental expenditure declined from 23.89 per cent in 1980-81 to 15.77 per cent 1990-91, 11.11 per cent in 2000-01 and 10.47 per cent in 2008-09. Revenue expenditure on health as a share of total government expenditure shows a declining trend reflecting the inadequate commitment of the state towards increasing health care demands of the population. This shows that the amount of health and family welfare was diverted somewhere else.

86 3.7 PANCHAYAT RAJ INSTITUTIONS AND PUBLIC HEALTH The local health department is that agency through which government delivers adequate health service to the community. 13 Maharashtra has a well functioning Panchayat Raj System since last five decades with administrative and financial powers delegated to these institutions. The state has a three-tier structure of PRI. Zila Parishad is the District level body having subject-based committees. The administrator at ZP level is Chief Executive Officer (IAS), while the Collector handles law and Revenue departments. Hence the CEO is the District Development Officer for the District. in the State of Maharashtra and hence he/she is also the Chairperson of the District Integrated Health and Family Welfare Society. All the development programs are run through Zila Parishad. Panchayat Samiti (PS) and Gram Panchayats PRI structure at block level and village level respectively. The personnel working at various levels are required to interact with the PRI members. Dist. Health Officer who is at par with Chief Medical Officer (Health) works under the control of Zila Parishad. Taluka Health Officers (THO) and Medical Officer (MO) PHC work in liaison with PS and sub-center staff works in liaison with the GP. The Zila Parishad is fully involved in planning, implementation and review of all health programs including RCH, which are implemented on agency basis through Zila Parishads. The PRI members at district level (Zila Parishad), block level (Panchayat Samiti) and village level (Village Panchayat) are regularly oriented and involved in various health initiatives. They play an active role in community level activities for motivating the villagers and stakeholders in CNA, demand generation and monitoring the functioning of various health programs. State has developed a training module for members of Panchayat Raj Institutions on various issues under NRHM with the help of UNFPA and State Rural Development institute (Subsidiary of YASHADA) the state run Development Administration Academy. The 3 day module has been finalized & the actual training/ sensitization of PRI members are being conducted in all

87 districts of the state. The state has also set up village health committees to monitor the health issues and liaison with the health institutions. 3.8 EXPENDITURE OF ZILLA PARISHADS ON PUBLIC HEALTH The Zila Parishad is the agency of rural local self government at the district level. The rural primary health services mainly PHCs and Sub-PHCs are working under administrative control of Zila Parishad. It means Zila Parishad is responsible for the health status of the rural mass at district level. To establish and provide management of hospitals, dispensaries and planning health centers are the functions of Zila Parishad government related to health of the people residing in rural area. The Zila Parishad incurred the expenditure on health under the head of Public Health. Table 3.2 shows that, the expenditure of Zila Parishad made by government on public health was increased from 98.58 crore in 1990-91 to 747.45 crore in 2006-07 with the growth rate of 6.12. However its percentage to total revenue expenditure was not so much changed. In fact C.G.R. shows the decreasing percentage of health expenditure to total revenue expenditure during the period of 1990-91 to 2006-07. It was also observed that Rural Per capita public health expenditure was very low and it increased from 17.67 to 144 during the same period with the growth rate of 17.67 per cent. It short, considering the overall period the expenditure of Zila Parishad on public health has decreased.

88 Table no. 3.2 Growth Profile of Expenditure of Zila Parishads on Public Health (1990-91 to 2006-07) Year Total Revenue Expenditure (in Cr.) Medical & Health Services (in Cr.) % of 3 to 2 Rural Per capita exp. on health by ZP govt. (census 2001) (in Rs.) 1 2 3 4 5 1990-91 1180.14 98.58 8.35 17.67 1991-92 1274.93 116.24 9.12 20.84 1992-93 1731.01 135.10 7.80 24.22 1993-94 2022.62 160.18 7.92 28.72 1994-95 2310.33 163.94 7.10 29.39 1995-96 2828.61 216.10 7.64 38.74 1996-97 3358.57 264.65 7.88 47.45 1997-98 3784.34 279.84 7.39 50.17 1998-99 4150.28 312.75 7.54 56.07 1999-00 4783.51 328.29 6.86 58.86 2000-01 5337.42 372.42 6.98 66.77 2001-02 5841.07 387.04 6.63 69.39 2002-03 5952.48 402.63 6.76 72.18 2003-04 6124.04 424.83 6.94 76.16 2004-05 6742.33 487.16 7.23 87.34 2005-06 7141.26 622.48 8.72 111.6 2006-07 8161.52 747.45 9.16 134 G.R. 6.92 7.58 1.10 17.67 C.G.R. 12.5813 12.1297-0.3981 12.12 Source : Economics Survey of Maharashtra

89 3.9 EXPENDITURE OF GRAM PANCHAYATS ON HEALTH AND SANITATION The Gram Panchayat is a village level local body and village is divided into wards. The cleanliness, sanitation, safe water supply, information to PHC about natural calamities and including epidemic, etc. are health related functions of Gram Panchayats. Gram Panchayats in Maharashtra State incurred expenditure on health and sanitation as shown below : Table 3.3 indicates that, the expenditure of Gram Panchayats on health and sanitation was increased from 16.34 crore in 1990-91 to 241.21 crore in 2006-07 with the growth rate of 14.76. However its percentage to total revenue expenditure was not much changed. The compound growth rate (1.0103 per cent) shows the fluctuations in the percentage of expenditure on health and sanitation to total expenditure incurred by Gram Panchayats. 3.10 MISMANAGEMENT OF BUDGETARY PROVISION The Maharashtra State is considered as a progressive State in India. But in the case of health subject we can see an extreme mismanagement in budgetary provision in the same State. The huge amount has been demanded every year on account of public health but actually State is unable to spend provisional amount which is average 60-70 per cent of the estimated budget 1. This revelation can be distressing for the State. The outcome budget of the Ministry of Health released from time to time showed that the State did not spend whooping amount out of their allocation. The non-utilisation of almost one third of the total allocation for different health programmes poses a serious question on the State willingness and capability to distribute the resources provided for the health of people.

90 Table no. 3.3 Expenditure of Gram Panchayats for the years 1990-91 to 2006-07 Year Total Expenditure ( in Cr.) Health and Sanitation ( in Cr.) % of 3 to 2 1 2 3 4 1990-91 80.47 16.34 20.31 1991-92 88.06 18.74 21.28 1992-93 100.60 24.27 24.13 1993-94 123.79 30.40 24.56 1994-95 135.81 33.19 24.44 1995-96 156.85 38.31 24.42 1996-97 223.73 69.16 30.91 1997-98 296.38 94.09 31.75 1998-99 352.43 127.91 36.29 1999-00 380.33 125.47 32.99 2000-01 399.31 107.26 26.86 2001-02 529.36 146.06 27.59 2002-03 544.39 148.18 27.22 2003-04 662.47 166.58 25.15 2004-05 758.44 192.34 25.36 2005-06 832.23 211.67 25.43 2006-07 938.58 241.21 25.70 G.R. 11.66 14.76 1.27 C.G.R. 17.7004 18.8905 1.0103 Source : i) Economic Survey of Maharashtra

91 Table no. 3.4 Budget of Public Health Department of Maharashtra State 2002-03 to 2006-07 (Rs. in crore) Year Estimated budget for public health Provision for on public health % of 3 to 2 Actual Expenditure on public health % of 5 to 3 1 2 3 4 5 6 2002-03 616 327 53.08 209 63.91 2003-04 698 477 68.34 303 63.52 2004-05 511 374 73.19 288 77.01 2005-06 769 401 53.15 305 76.06 2006-07 820 418 50.98 277 66.27 Average 59.54 69.35 Source : Economics Survey of Maharashtra (various years) Table no. 3.4 indicates that, during 2002-03 State Government had somehow managed to spend 209 (63.91 %) crore out of 327 crores of allocation. After some ups and downs during 2006-07 State Government had spent 277 (66.27) crores on public health out of total allocation of 418 crores. The State Government has failed in spending the allocated amount. An average spending on public health is less than 70 per cent of its allocated budget during year of 2002-03 to 2006-07. Outcome budget did not mention the reasons behind such huge unspent money on ongoing health programmes but it is understood that lack of will on the part of State Government, bureaucratic red tapism, nonrecruited officers or staff and corruption were the major factors.

92 3.11 INFRASTRUCTURE OF RURAL PUBLIC HEALTH SERVICES IN MAHARASHTRA Generally, the health status of the people depends on the easy availability of the health care services. Therefore, the availability of basic health facilities is considered as an important determinant of health status. 3.11.1 DISTRICTWISE NUMBER OF SUB-PHC, PHC AND CHC IN MAHARASHTRA Availability of public health care services is essential to know the health status of people of the particular state. In the health care sector, we can see the disparity in spread of rural public health care services across the Maharashtra State. The table no. 3.5 indicates the district wise number of public health centers in Maharashtra State. The table also shows inter district disparity in number of public heath centers. Nashik District has the highest number of Sub- PHCs (577), PHCs (106) and CHCs (26). On the other side, Hingoli District has the lowest in number of Sub-PHCs (132), PHCs (24) and CHCs (5) in the Maharashtra State. The table also indicates that, Vidarbha and Marathwada have less number of public health centers compared to western maharashtra. The average number public health center is Sub-PHCs (320), PHCs (55) and CHCs (12). However, the district such as Akola, Aurangabad, Bhandara, Beed, Buldhana, Dhule, Godiya, Hingoli, Jalana, Latur, Nandurbar, Parbhani, Raigarh, Sindhudurga, Wardha and Washim are having a less number of Sub-PHC, PHC and CHC/RH than average number.

93 Table no. 3.5 District wise Number of Sub-PHC, PHC and CHC in Maharashtra State Sr. no. District No. of Sub-PHC No. of PHC No. of RH/CHC 1 Ahmadnagar 555 96 21 2 Akola 178 30 6 3 Amravati 333 56 13 4 Aurangabad 279 50 8 5 Bhandara 193 33 8 6 Beed 280 50 13 7 Buldana 280 52 14 8 Chandrapur 339 58 13 9 Dhule 232 41 7 10 Gadchiroli 376 45 12 11 Gondiya 237 39 10 12 Hingoli 132 24 5 13 Jalgaon 442 77 20 14 Jalna 213 39 9 15 Kolhapur 413 72 17 16 Latur 252 46 11 17 Nagpur 316 49 11 18 Nanded 377 64 14 19 Nandurbar 290 58 12 20 Nashik 577 106 26 21 Osmanabad 206 42 8 22 Parbhani 214 31 8 23 Pune 539 96 23 24 Raigarh 288 55 13 25 Ratnagiri 378 67 10 26 Sangli 320 59 11 27 Satara 400 71 14 28 Sindhudurg 248 38 10 29 Solapur 431 77 13 30 Thane 492 79 14 31 Wardha 181 27 8 32 Washim 153 25 8 33 Yavatmal 435 63 17 Maximum 577 106 26 Minimum 132 24 5 Average 320.58 55 12.333 S.D. 118.63 21.026 4.871 C.V. 0.370 0.382 0.395 Source : Directorate of Health Services, Government of Maharashtra, Pune.

94 3.12 INDICATORS OF HEALTH IN MAHARASHTRA STATE The health status of the people is determined by numerous factors such as per capital income, way of life, housing, sanitation, water supply, nutrition, education, geography, climate, etc. However, the State Government expenditure on public health and existing health infrastructure are the most influential aspects of health status of the people. In other words, Health indicators are the outcome of State Government s expenditure on public health and wide spread of public health care system in the state. Up to now, we have studied the State Government s and Local Government s expenditure on public health and State wide infrastructure of health care services. Now it is time to find relation between Government health expenditure and health indicators. Health has to be defined from a practical point of view and, therefore, it has been defined according to life expectancy, infant mortality, and crude death rate, etc. 14 Basic indicators of health like birth rate, death rate, infant mortality rate, total fertility rate as well as life expectancy give broad picture of health status of a State. They can be used for assessing specific health care needs and also for evaluating quality of health services and programs. In the present study health status is examined by the movement of health indicators. Table no. 3.6 shows that, birth rate in rural area of Maharashtra State was declined from 28.0 in 1991 to 18.1 in 2009 while total birth rate of Maharashtra State also reduced from 26.2 to 17.6 in the same period. It shows the birth in rural area is still higher compare to total birth rate; the total birth rate consists of rural and urban birth rate. Decrease in birth rate shows the people s awareness regarding the benefits of small family. The decline in birth rate which is a positive signal of health has been attributed to national family planning program, which is implemented through the network of public health care services.

95 Table no. 3.6 Selected Health Indicators in Maharashtra State (1991-2008) Year Birth Rate Death Rate Infant Mortality Rate Total Fertility Rate Life Expectancy at Birth (years) Rural Total Rural Total Rural Total Rural Total Total 1991 28.0 26.2 9.8 8.2 69 60 3.4 3.0 64.80 1992 27.4 25.3 9.1 7.9 67 59 N.A. N.A. 64.80 1993 27.1 25.2 9.3 7.3 63 50 N.A. N.A. 64.80 1994 26.9 25.1 9.2 7.5 68 55 N.A. N.A. 64.80 1995 26 24.5 8.9 7.5 66 55 N.A. N.A. 64.80 1996 24.9 23.4 8.7 7.4 58 48 3.2 2.6 65.35 1997 24.4 23.1 8.6 7.3 56 47 N.A. N.A. 65.35 1998 23.6 22.5 8.9 7.7 58 49 N.A. N.A. 65.35 1999 21.6 21.1 8.7 7.5 58 48 N.A. N.A. 65.35 2000 21.4 21 8.6 7.5 56 48 N.A. N.A. 65.35 2001 21.1 20.7 8.5 7.5 55 45 2.6 2.1 69.63 2002 20.6 20.3 8.3 7.3 52 45 2.5 2.3 69.63 2003 20.1 19.9 8.2 7.2 48 42 2.4 2.3 69.63 2004 19.9 19.1 6.8 6.2 42 36 2.4 2.2 69.63 2005 19.6 19.0 7.4 6.7 41 36 2.4 2.2 69.63 2006 19.2 18.5 7.4 6.7 42 35 2.3 2.1 69.63 2007 18.7 18.1 7.3 6.6 41 34 2.2 2.0 69.63 2008 18.4 17.9 7.4 6.6 40 33 2.1 2.0 69.63 2009 18.1 17.6 7.6 6.7 37 31 2.1 2.0 70.5 Source : Economic Survey of Maharashtra 2008-09

96 Death rate has considerably declined from 9.8 in rural area and 8.2 in overall Maharashtra in 1991 to 7.4 in rural area and 6.7 in overall Maharashtra in 2009. It has been attributed to mass control of diseases and advance in medical science, better health facilities and impact of national health programs. Infant mortality rate is one of the most universally accepted indicator of health status not only of infants, but also of whole population and the socioeconomic condition where they live. According to table, it has declined from 69 in rural area and 60 in overall Maharashtra in 1991 to 40 and 31 respectively in 2009. Total fertility rate represents the average of children a woman would have if she were to pass through her reproductive years bearing children at the same rates as the women now in each age group. 15 It is selected as a health indicator because every childbirth influences the health of woman, and frequent pregnancies can deteriorate the health of women. According to the table total fertility rate in rural area declined from 3.4 in rural area and 3.0 overall Maharashtra in 1991 to 2.2 and 2.0 in 2009, which will be helpful for the improvement of health of women. Life expectancy is a good indicator of health status of people in the state. As an indicator of long term survival, it can be considered as a positive health indicator. The trend in life expectancy shows that, people are living longer, and they have a right to a life in a good health. The present life expectancy of people in the State is 70.5 years, which was 64.80 years in 1991. Demographer opined that further increase in life expectancy may be continuing in future. 3.13 RURAL HEALTH SERVICES AND NIGATIVE ATTITUDE OF MAHARASHTRA GOVERNMENT Even though, Maharashtra has been at the forefront of the health care development in India and one of the first States to achieve the norms mandated for PHC, Sub- PHC and RH, the real picture of rural public health services

97 shows the dismal of state government. The government has concealed their lacunas in the parade. Here, the researcher has made an attempt to bring forward these lacunas. It will catch the attention of the government and the State will make endeavour to remove these lacunas. It will be helpful to place Maharashtra in the forefront of parade of health care development in real meaning. 3.13.1 SHORTFALL OF MANPOWER Shortfall of manpower is the most distressing difficulty before rural public health services. The detail information about shortfall of manpower at the each level health centre is discussed in this part of study. 3.13.1.2 SHORTFALL OF MANPOWER AT SUB-PHC MAHARASHTRA STATE Sub-primary health center is first contact point between the patient and public health care system. And the problem of lack of manpower also begins from the grass root level. The shortfall of the manpower at sub center level is given bellow: Table no. 3.7 Shortfall of Manpower at Sub-PHC Maharashtra State (As on March 2008) Name of the post Required Sanctioned In Position Vacant Shortfall R S P S-P R-P HW(F)/ANM 12395 12645 12027 618 368 HW(M)/MPW 10579 12210 9956 2254 623 Source : Rural health bulletin 2008 Table no. 3.8 Shortfall of Manpower at Sub Centre in Trabal Area of Maharashtra State (As on March 2008) Name of the post Required Sanctioned In Position Vacant Shortfall R S P S-P R-P HW(F)/ANM 2075 2025 1536 489 539 HW(M)/MPW 2075 2025 1006 1019 1069 Source : Rural health bulletin 2008

98 Table no. 3.7 and 3.8 indicate that, sub-phcs in rural area are facing the problem of short fall of 368 female health workers and 1069 male health worker who are backbone of the concerned system. On the other hand Sub- PHCs in tribal area need 539 female health worker and 1069 male health workers. 3.13.1.2 SHORTFALL OF MANPOWER AT PHC OF MAHARASHTRA STATE Primary health centers are working at the second stage in rural public health system. It is the first referral unit for sub-phc. The shortfall of man power at this secondary stage is as follow : Table no. 3.9 Shortfall of Manpower at PHC of Maharashtra State (As on March 2008) Name of the post Required Sanctioned In Position Vacant Shortfall R S P S-P R-P Doctors 1816 1800 1191 609 625 HA (F)/LHV 1816 3740 3323 417 1399 HA (M) 1816 4598 3182 1416 400 Source : Rural health bulletin 2008 Table no. 3.10 Shortfall of Manpower at PHC in Tribal Area of Maharashtra State (As on March 2008) Name of the Post Required Sanctioned In Position Vacant Shortfall R S P S-P R-P Doctors 320 316 280 36 40 HA (F)/LHV 320 316 316 0 4 HA (M) 320 316 241 75 79 Source : Rural health bulletin 2008 Table no. 3.9 and 3.10 show that, shows that in case of rural area, there was a shortfall of 625, 1399 and 400 for the post of doctor, female health assistant and male health assistant respectively in PHC. In case of tribal area there is a shortfall of 40, 04 and 79 for the same posts in Maharashtra State.

99 3.13.1.3 SHORTFALL OF MANPOWER AT CHC OR RH IN MAHARASHTRA STATE Rural hospitals or community health centers are the first referral unit for the PHC and second referral unit for the Sub-PHC. It is mostly working as a curative unit. It is the most significant and upper level part of rural public health care services. Table no. 3.11 Shortfall of Manpower at RH in Maharashtra State (As on March 2008) Name of the post Required Sanct- In Vacant Shortfall ioned Position R S P S-P R-P Surgeon 407 53 69 * 338 Obstetricians & 407 133 143 * 264 Gynaecologists Physicians 407 59 41 18 366 Paediatricians 407 69 99 * 308 Total Specialists 1628 314 352 * 1276 Radiographer 407 407 294 113 133 Source : Rural health bulletin 2008 Table no. 3.12 Shortfall of Manpower at RH in Tribal Areas of Maharashtra State (As on March 2008) Name of the Post Required Sanct- In Vacant Shortfall ioned Position R S P S-P R-P Surgeon 69 71 17 54 50 Obstetricians & 67 71 28 43 39 Gynaecologists Physicians 67 71 7 64 60 Paediatricians 67 71 23 48 44 Total Specialists 268 284 75 209 193 Radiographer 67 71 52 19 15 Source : Rural health bulletin 2008 Table no. 3.11 and 3.12 show that, though rural hospitals are a vital link of rural public health care chain, yet there is shortfall of health specialist like surgeons, obstetricians and gynaecologists, physicians and paediatricians. These are indispensable aspects of the rural hospitals. If these specialists are not available in the hospital then no patients come to the rural hospitals for cure

100 of their disease. Nevertheless, total 407 rural hospitals in the state have shortfall of 338 surgeons, 264 obstetricians and gynaecologists, 366 physicians and 308 paediatricians. On the other hand rural hospitals in tribal area have a shortfall of 50 surgeons, 39 obstetricians and gynaecologists, 60 physicians and 44 paediatricians. In short, most of the rural hospitals are functioning without the specialists. 1.13.1.4 SHORTFALL OF PHARMACISTS, LABORATORY TECHNICIANS AND NURSE MIDWIFE/STAFF NURSE AT PHC AND RH OR CHC IN MAHARASHTRA STATE Pharmacist s and laboratory technician s posts are as important as doctors and paramedical staff. The shortfall of these posts at PHC and RH is given bellow: Table no. 3.13 Shortfall of Pharmacists, Laboratory Technicians and Nurse Midwife/Staff Nurse at PHC and RH in Maharashtra State (As on March 2008) Name of the post Required Sanctioned In Position Vacant Shortfall R S P S-P R-P Pharmacists 2223 2367 1976 391 247 Laboratory Technicians 2223 803 769 34 1454 Source : Rural health bulletin 2008 Table no. 3.14 Shortfall of Pharmacists, Laboratory Technicians and Nurse Midwife/Staff Nurse IN Tribal Area of Maharashtra State (As on March, 2008) Name of the Required Sanctioned In position Vacant Shortfall post (R) S P S-P R-P Pharmacists 387 387 322 65 65 Lab technicians 387 387 356 31 31 Source : Rural health bulletin 2008

101 Table no. 3.13 and 3.14 show the shortfall of 247 pharmacists and 1454 lab technicians in rural area and 65 pharmacists and 31 lab technicians in tribal area of Maharashtra State. It means that considering the requirement of manpower the State Government has sanctioned the posts, but most of the posts in the rural public health centers are still vacant. Hence, rural public health system suffered the problem of shortfall of staff in one hand and excess burden on available staff on the other. 3.13.2 BUILDING POSITION OF RURAL PUBLIC HEALTH SYSTEM Establishment of building facilities of health center is one of the basic requirements for health care delivery. Building of health care center is a one time but a huge investment for the government. Therefore in the initial phase of public health care services, it was not possible to the government for afford such huge investment for establishment of building for every health center at once. Hence, it was decided that, the building would be hired, rental or rental free voluntary basis from Gram Panchayat building or private owner. With the time, government made provision for building fund and buildings were built for the health centers. At present most of the health centers are functioning in their own buildings but a few are still functioning in the rental building. Name of health center Table no. 3.15 Position of Buildings for Sub-PHC, PHC and RH/CHC in Maharashtra State (As on March 2008) No. of health center no. of sub-centers functioning in Govt Rented Build Building Rent free Panchayat/ vol. soci. Buildings Building under counstruction Building required to be constructed Sub-PHC 10579 7442 867 2270 650 2487 PHC 1816 1518 10 288 137 161 RH/CHC 407 297 4 106 38 72 Source : Rural health bulletin 2008