Meghalaya didn’t spend 76% of NHM funds in 2015-16. But why?

Guwahati: Meghalaya accounts for 76%, the highest amount among all Indian states, of unspent funds under the National Health Mission’s (NHM) special reproductive and child health (RCH) programme for the year 2015-16. The alarming fact was revealed in an audit report by the Comptroller and Auditor General (CAG) of India sometime ago.

The report highlights that in 27 states of India, the amount of unspent funds meant for the RCH programme by state health societies went up from Rs 7,375 crore in 2011-12 to Rs 9,509 crore in 2015.

The NHM, launched in 2005, is India’s largest health programme aimed at providing universal access to healthcare. One of its primary missions is to improve maternal and child health and control communicable and non-communicable diseases.

NHM is funded in a 60:40 ratio by both the central government and the states. Interestingly, the ministry of health and family welfare used to release funds directly to the state health societies till 2013-14. But, the money is now sent to state governments, which then move it to the societies, which in turn disburse the funds to district health societies for further release to blocks and further down to the community, primary health and sub-centres.

However, despite the fact that as per a procedure laid out by the Union Cabinet to penalise the states which do not spend the money allocated to them which was to be applicable from 2014-15, no such action has been initiated against such defaulting states. The government auditor highlights that Rs 49 crore released during 2014-15 and Rs 450 crore released during 2015-16 under Mission Flexipool and RCH Flexipool to state treasuries were not transferred to state health societies as of May 2016.

Speaking to EastMojo, Pravin Bakshi, director, NHM Meghalaya, said, “Sometimes the funds disbursed are delayed by the ministries concerned, which leads to the delay in submission of utilisation certificates on time.”

Highlighting the importance of the timely disbursal of funds, Bakshi further added, “If we receive the funds meant for various programmes under NHM at the end of the financial year, it would naturally take time for the funds to reach the respective health centres of various districts.”

Have other NE states fared any better?

Apart from the irregularity in spending of funds in Meghalaya, other Northeastern states of India have not fared any better, with many inconsistencies being pointed out in the report, ranging from non-availability of doctors and non-functional healthcare centres with dilapidated equipment, among other anomalies.

The C&AG undertook the survey of 1,443 sub-centres (SCs), 514 primary health centres (PHCs), 300 community health centres (CHCs) and 134 district hospitals (DHs) countrywide and the report mentions several instances of health facilities being misused with “unauthorised occupation by gram panchayats, anti-social elements, private persons, etc”. It observes that of the 55 PHCs upgraded in Assam and Manipur, 14 were non-functional due to shortage of manpower and lack of emergency services, with some of them operating for just five hours a day.

The audit report further highlighted the inordinate delay in transfer as well as misallocation of funds, with six states including Tripura where Rs 36.31 crore was diverted to other schemes, instead of RCH.

Inadequate availability of basic healthcare facilities:

In terms of availability of SCs, PHCs and CHCs in states, there was more than 50% shortfall in five states including Sikkim, but other Northeastern states such as Assam has also reported quite high shortfall in availability of such critical health facilities, with a shortfall of as much as 1,112 against the requirement of 6,817 SCs. Tripura, for instance, has a shortfall of 10 CHCs against the requirement of 30, and a shortfall of 24 PHCs against a requirement of 109 in Manipur.

What is RCH all about?

The RCH programme is an important sub-component of NHM and it essentially aims at improving the health outcome indicators, namely, infant mortality rate and maternal mortality ratio, apart from controlling communicable and non-communicable diseases.

The other key feature of the programme is to ensure that the public health delivery system becomes fully functional and accountable to the community, human resource management, rigorous monitoring and evaluation against standards, among other things.

Other discrepancies

In as many as five states of north-east including Assam, Manipur, Meghalaya, Sikkim and Tripura, instances of non-availability of essential drugs were observed, including essential medicines such as Vitamin-A tablets, contraceptive pills, ORS packets, essential obstetric kits, etc, in selected health facilities. Apart from non-availability of medicines, in Assam, Manipur, and Tripura, among other Indian states, “medicines were issued to patients without ensuring the prescribed quality checks and without observing the expiry period of drugs, thus exposing the patients to health risks”.

With the aim of providing health facilities to the remotest corners of the state, NHM had even introduced the service of mobile medical units (MMUs) but the services provided by them were largely deficient in the states of Assam and Meghalaya, apart from seven other Indian states. A shortage of more than 50% in availability of mobile health teams was noticed in Arunachal Pradesh, Assam, Manipur, Mizoram, Nagaland, Sikkim and Tripura.

NHM also requires the states to constitute state quality assurance committee (SQAC) with the aim of ensuring the improvement of state health services. However, astonishingly, not a single review meeting of the SQACs were held in the several states, including Assam, Manipur and Tripura, between 2013-16. The negligence of duty does not stop here, the SQAU, which is supposed to support the SQAC’s quality assurance activities, were not even constituted in the three states of Assam, Meghalaya and Odisha.

The Janani Suraksha Yojana (JSY) was launched in April 2005 under the NHM and was aimed at providing conditional cash transfer to a pregnant woman for institutional care during delivery. However, the CAG audit reveals that in “six states including three NE states of Arunachal Pradesh, Manipur, and Meghalaya, the percentage of registered pregnant women opting for institutional delivery during 2011-16 was less than 50, with the lowest percentage being recorded in Manipur (38) and Meghalaya (34).”

The NHM further aims to establish referral chain from village to hospital, that is, assured referral linkages for timely and assured referral to functional PHCs/FRUs in case of complications during pregnancy and child birth. However, audit observations in providing referral services found that in four states of Arunachal Pradesh, Assam, Manipur, and Meghalaya these services were among the poorest in the country.

Among other discrepancies, around “55,000 vials (5,50,000 doses) of Pentavalent vaccines meant to protect people from multiple diseases, shipped for Assam were received in Guwahati in 2014 in a damaged condition. However, the damaged vials (12,000 doses) costing Rs 15.51 lakh had not been replaced until August 2016,” states the report.

Eleven out of 30 PHCs in Assam did not even have a single cold chain equipment to store some important lifesaving vaccines. Apart from the neglect in maintenance of vaccines, six states — Arunachal Pradesh, Assam, Manipur, Meghalaya, Nagaland and Tripura — had no district early intervention centre (DEIC) at the district hospital meant to provide referral support to the children detected with health problems.

Such anomalies, especially at a time when India ranks lower than the neighbouring Bangladesh, sub-Saharan Sudan and Equatorial Guinea on healthcare access in 2016, as per a Lancet study on Global Burden of Disease Study, raises some serious doubts on the intention of the successive governments in tackling the issues pertaining to healthcare.

India still spends a meagre 1.4% of its GDP on health, which is the least among all of the BRICS nations. India also accounts for some large gaps between locations with the highest and lowest scores in 2016, with a “30·8-point disparity, from 64·8 (59·6–68·8) in Goa to 34·0 (30·3–38·1) in Assam”, as per the study.