National Disease Control Programs - Recent Trends in Financing


Ravi Duggal
Sunil Nandraj

Selected diseases have at different points of time received special attention and separate allocation of resources. In the past small pox was one such disease which had a separate budget and staff to tackle the problem on a war footing. In the past many such programs were of a vertical nature having their own budgets and staff. Malaria and leprosy programs, apart from small pox were the main vertical programs. While the war against small pox was successful, that against malaria reached a certain success in the mid-60s but after that malaria has come back with a vengeance and continues to be a major program (but without its vertical structure). Leprosy continues to be a vertical program and in recent years has shown good results. The tuberculosis and the blindness control programs have had no such luck and have always received a step-motherly treatment under public health care.

Disease Programs on an average during this decade have received 10 percent of the State's health care budget and the trend is a declining one1. In per capita terms at the national level today a measly amount of Rs.8 per person is being spent on these programs. If one looks at the disease profile of the country then this expenditure itself is very low to fight these diseases. (Of course, it must be noted that three-fourth of health care is sought in the private sector hence the actual per capita value would be four times.) If we break down the expenditure by various diseases we find that between 80 per cent and 95 per cent is spent on just four programs malaria, leprosy, in tuberculosis and blindness. Further, of the total disease program expenditure 50 per cent to 60 per cent is spent on the malaria program alone, followed by about 20 per cent on leprosy. Tuberculosis and blindness control get under five per cent.

The prevalence of malaria is very high right across the length and breadth of the country, with only Kerala and Goa being exceptions. The NFHS study in 1992-93 gives a 3 month incidence rate of 3324 per 100,000 population, which means about 105 million new cases every year. The rural areas recorded an incidence of nearly twice that of urban areas. While most states show a fairly high share of expenditure for the malaria program from the total disease program budget, it must be noted that most of it goes to salaries of staff who may not be doing any work related to malaria. For historical reasons most multipurpose workers (MPWs) get their salary from the malaria department because they were erstwhile malaria workers and today are MPWs who may be doing very little malaria related work. Hence, what actually is spent to treat or control malaria may be a very small amount of the national malaria budget of about Rs.5000 million which initself may be quite adequate to fight malaria under a comprehensive health program.

According to the 1981 census India had 4.2 million active leprosy cases. The NFHS survey a decade later in 1992-93 recorded a prevalence rate four times less than the 1981 census making for a caseload of 1.2 million cases. While one may argue that the NFHS may have made an undercount there is no doubt that the leprosy program has had a major impact, and this perhaps due to three reasons - reasonably sufficient allocation of funds, better management of the program albeit through a vertical structure, and treatment largely being availed in the public sector.

The tuberculosis control program is perhaps the worst performer and the main reason is very poor allocation of funds in the public system. Further, since tuberculosis begins symptomatically with cough and fever it is treated mainly in the private sector which exploits patients with irrational therapy comprising of cough syrups, tonics and broad spectrum antibiotics. Today there are about 14 million estimated active cases of TB in the country and the state pays very little attention to it. An evaluation team of GOI-WHO-SIDA found that the drugs available in the public system were sufficient to treat only one-third of the patients who actually were receiving care within the public system - this means that the average patient would get only one-third of the treatment required and hence would return with a relapse.

With nine million blind persons and 45 million with severe visual impairment this is a very serious scenario. The present focus is on cataract surgery and vitamin A deficiency. The care of the completely blind is under the social welfare department. The resources available for handling cataract and vitamin A deficiency cases is very meagre and needs to be enhanced substantially.
Of the budgets allocated for various programs salaries take away 70 per cent to 90 per cent of the resources leaving very little behind for other inputs like drugs, equipments, travel etc. While one recognises that the health sector is clearly a labour intensive one where human resource is the most valuable input, it cannot be denied that without adequate drugs, diagnostics etc, the human resource has little value. Thus if in the present situation 80 per cent of the resource, and increasingly so, goes for paying salaries then the health workforce cannot be effective with the meagre resources left over to treat patients, and for preventive and promotive care. If for instance we look at the teaching hospital or other large city hospitals we find that salaries account for about 40 per cent of the budget and thus these hospitals perform more effectively than their rural counterparts like rural hospitals and primary health centres. It must be emphasised here that percentages have been used in the data only as a proxy tool. A more realistic analysis would include using morbidity data to determine the financial requirements or costs needed to deal with it. Unfortunately at the present moment such data is difficult to come by, though we have made a brief attempt in Table 4, but its limitations are explained in the table itself.


Table 1 : Expenditure On Selected Disease Programs (Selected States)
   Year Malaria TB Leprosy Blindness AIDS All Disease Total Health
(As percentages to total health)                      (Rs millions)
Andhra Pradesh
1990 - 1991 10.11 1.25 4.62 .21 .00 16.11 3325.10
1994 - 1995 9.82 1.42 4.97 .28 .48 18.79 5043.53
Assam
1990 - 1991 7.36 1.42 1.48 .75 .00 17.29 941.22
1994 - 1995 3.90 .97 1.32 .80 .00 7.26 1883.92
Bihar
1992 - 1993 4.96 .27 3.39 .12 .00 9.18 3856.38
1994 - 1995 5.41 .19 2.89 .08 .00 10.34 5574.54
Gujarat
1990 - 1991 4.59 2.48 1.78 .84 .00 10.89 2478.16
1994 - 1995 7.12 2.95 1.60 .78 .41 13.76 3593.73
Haryana
1990 - 1991 10.72 1.81 .08 .24 .00 12.30 917.60
1994 - 1995 11.57 4.36 .05 .75 .50 15.33 1396.29
Karnataka
1990 - 1991 3.40 1.80 .84 .29 .00 4.70 2698.20
1994 - 1995 3.27 1.90 .95 .47 .69 5.58 5077.72
Kerala
1990 - 1991 1.43 .80 .99 .20 .00 3.96 2224.32
1994 - 1995 1.75 1.01 1.53 .45 .05 5.98 3759.77
Madhya Pradesh
1990 - 1991 7.18 .37 2.36 .70 .00 11.02 2647.20
1994 - 1995 7.12 2.31 1.86 .86 .60 8.84 4609.97
Maharashtra
1990 - 1991 8.58 2.80 3.00 .10 .07 14.34 4341.15
1994 - 1995 6.60 2.48 2.85 .07 .41 11.87 6803.92
Orissa
1990 - 1991 5.36 1.46 3.66 .17 .00 11.29 1550.21
1991 - 1992 5.73 1.67 4.33 .27 .00 10.98 1565.99
Punjab
1990 - 1991 8.43 1.72 .14 .18 .00 11.88 1765.76
1994 - 1995 5.67 2.31 .19 .38 .48 6.90 2312.75
Rajasthan
1990 - 1991 6.66 2.56 .40 .26 .00 8.65 2555.20
1994 - 1995 5.74 2.23 .36 .44 .14 8.18 4556.96
Tamil Nadu
1992 - 1993 * 1.38 3.54 .28 .04 4.83 4894.22
1994 - 1995 * 1.57 3.63 .26 .02 6.20 5982.37
Uttar Pradesh
1990 - 1991 7.84 3.07 2.45 .51 .00 15.85 5826.32
1994 - 1995 7.11 2.16 1.93 .34 .14 17.35 8003.05
West Bengal
1990 - 1991 6.89 3.74 2.43 .23 .00 13.20 3256.13
1994 - 1995 4.27 3.07 1.63 .23 .15 9.18 5397.64
Arunachal Pradesh
1990 - 1991 2.60 2.24 .86 .33 .00 19.14 144.86
1994 - 1995 4.57 2.40 .68 .21 .00 11.73 278.07
Goa
1990 - 1991 .99 2.77 1.70 .36 .00 5.51 232.15
1994 - 1995 .77 2.31 1.43 .33 .29 5.13 350.86
Notes :* Data breakup not available; 1994-95 data are budget estimates
Sources : Respective State government, Demand for Grants, 1993 - 94 and 1994 - 95.

Table 2 : Expenditure On Salaries For Disease Programs (selected States)
Year Malaria Tuberculusois Leprosy Blindness
  As per Cent Actuals As per Cent Actuals As per Cent Actuals As per Cent Actuals
Andhra Pradesh
1990 - 1991 80.00 336.46 82.53 41.85 85.22 153.69 10.21 7.05
1994 - 1995 93.29 495.42 81.91 71.58 88.88 250.64 8.43 14.36
Assam
1990 - 1991 .00 69.32 16.60 13.43 .00 14.02 .00 7.10
1994 - 1995 9.55 73.51 56.59 18.20 56.64 24.91 .00 15.06
Bihar
1992 - 1993 95.25 191.25 2.90 10.34 99.54 130.74 38.66 4.63
1994 - 1995 86.88 301.39 3.24 10.49 104.70 161.19 34.34 4.63
Gujarat
1990 - 1991 5.90 113.95 57.38 61.47 68.54 44.22 62.75 21.02
1994 - 1995 3.80 256.03 41.70 105.85 67.63 57.67 79.57 28.10
Haryana
1990 - 1991 81.14 98.41 60.75 16.61 58.11 .74 11.76 2.21
1994 - 1995 77.95 161.51 39.60 60.83 77.27 .66 .00 10.54
Karnataka
1990 - 1991 .00 91.97 66.92 48.82 35.60 22.67 .00 7.85
1994 - 1995 24.06 166.27 48.26 96.65 10.50 48.48 .00 23.80
Kerala
1990 - 1991 92.05 31.95 51.96 17.90 97.69 22.04 89.24 4.46
1994 - 1995 90.80 65.86 53.59 37.90 96.67 57.37 70.80 16.92
Madhya Pradesh
1990 - 1991 79.81 190.22 35.36 10.04 83.83 62.72 66.29 18.66
1994 - 1995 66.18 328.04 73.61 106.56 86.50 85.95 61.13 39.46
Maharashtra
1990 - 1991 68.25 372.50 49.66 121.84 80.87 130.39 .00 4.43
1994 - 1995 76.40 448.81 48.48 168.50 78.59 194.07 .00 5.04
Orissa
1990 - 1991 82.74 83.14 69.37 22.72 85.53 56.88 92.83 2.79
1991 - 1992 84.05 89.68 72.72 26.21 86.88 67.75 32.70 4.22
Punjab
1990 - 1991 68.28 148.98 79.32 30.41 91.13 2.48 52.94 3.23
1994 - 1995 83.45 131.15 65.38 53.50 87.05 4.48 55.77 8.75
Rajasthan
1990 - 1991 71.46 170.37 67.49 65.61 88.96 10.24 33.53 6.77
1994 - 1995 71.41 261.60 62.84 101.57 92.04 16.59 17.98 19.85
Tamil Nadu
1992 - 1993 * .00 55.52 67.53 92.93 173.10 78.92 13.66
1994 - 1995 * .00 52.20 94.00 93.32 217.01 85.02 15.75
Uttar Pradesh
1990 - 1991 72.48 457.20 86.11 179.33 77.41 143.09 62.14 30.16
1994 - 1995 75.09 569.33 59.15 172.87 80.34 154.19 50.92 27.20
West Bengal
1989 - 1990 96.31 147.75 77.01 96.05 87.97 63.36 92.53 4.82
1994 - 1995 94.72 230.59 72.52 165.56 91.81 87.87 81.29 12.56
Arunachal Pradesh
1990 - 1991 93.39 3.78 88.62 3.25 92.80 1.25 .00 .49
1994 - 1995 78.52 12.71 68.97 6.67 89.95 1.89 .00 .59
Goa
1990 - 1991 78.88 2.32 82.61 6.44 82.78 3.95 92.86 .84
1994 - 1995 85.93 2.70 86.42 8.10 87.20 5.00 93.10 1.16
Notes : * Data not available; Actuals are in Rs. millions spent on each disease program.
Sources : Respective state government, Demand for Grants, 1993 - 94 and 1994 - 95.

TABLE 3 PREVALENCE OF SELECTED DISEASES 1992 - 1993(per 100,000 population)
STATE MALARIA TUBERCULOSIS LEPROSY BLINDNESS
ANDHRA PRADESH 7776 407 118 5984
ASSAM 10828 638 36 1106
BIHAR 5712 595 123 2749
GUJARAT 12912 308 29 3266
HARYANA 3732 327 14 824
JAMMU & KASHMIR* 3412 245 18 869
KARNATAKA 1828 136 132 4900
KERALA 448 586 18 1404
MADHYA PRADESH 18912 435 136 3831
MAHARASHTRA 14968 293 72 3534
ORISSA 20592 555 96 3161
PUNJAB 10184 238 28 863
RAJASTHAN 20412 724 128 4661
TAMIL NADU 2304 703 209 836
UTTAR PRADESH 29580 560 222 3101
WEST BENGAL 2712 357 47 914
ARUNACHAL PRADESH 16852 938 110 1012
GOA 972 179 16 2714
MIZORAM 18544 311 33 1524
HIMMACHAL PRADESH 4564 242 56 1384
MANIPUR 6564 941 199 1442
MEGHALAYA 22892 321 17 759
NAGALAND 11112 491 153 1373
SIKKIM NA NA NA NA
TRIPURA 10476 289 0 1430
INDIA 13296 467 120 3001
Notes : 1) * = Refers only to Jammu region.
2) Malaria data is incidence of cases. The NFHS data was for 3 months, we multiplied it by 4 to arrive at the annual figure. For other diseases it is point prevalence.
Source : National Family Health Survey 1992-93 : All India, International Institute for Population Sciences, Bombay, August 1995 (Pg. 205, Tables 8.2)

TABLE 4 : NORMATIVE EXPENDITURE INCURRED PER CASE 1992 - 1993

The per case expenditure is a normative figure because it is well known that a) actual utilisation of these government programs is only by one fourth to one third of the population and b) the establishment costs (salaries etc.) takes away about three fourth of this expenditure. Therefore, the real expenditure per actual case is much higher, but this data helps us look at allocations in terms of disease prevalence across diseases.

(in Rupees)
STATE MALARIA TUBERCULOSIS LEPROSY BLINDNESS
ANDHRA PRADESH 77 186 2445 3
ASSAM 29 52 2448 24
BIHAR 37 19 1175 2
GUJARAT 29 587 4693 18
HARYANA 210 567 189 43
JAMMU & KASHMIR* NA NA NA NA
KARNATAKA 157 1001 427 5
KERALA 274 96 5875 12
MADHYA PRADESH 14 214 811 9
MAHARASHTRA 33 529 3002 2
ORISSA 13 146 2185 4
PUNJAB 76 567 390 22
RAJASTHAN 22 207 281 6
TAMIL NADU NA 167 1438 28
UTTAR PRADESH 15 158 891 8
WEST BENGAL 109 448 2484 25
ARUNACHAL PRADESH 43 658 2431 280
GOA 212 3426 24070 47
MIZORAM 52 1985 12444 136
HIMMACHAL PRADESH 186 593 3628 49
MANIPUR 46 270 1690 56
MEGHALAYA 42 733 19265 139
NAGALAND 116 1386 2919 68
SIKKIM NA NA NA NA
TRIPURA 33 124 NA 59
INDIA NA NA NA NA
Notes : 1) * = Refers only to Jammu region. 2) The expenditure figures for Orissa and Manipur refer to year 1991-92
Source: Prevalence data: National Family Health Survey 1992-93 : All India, International Institute for Population Sciences, Bombay, August 1995 (Pg. 205, Tables 8.2)
Expendiute data : Respective state government Demand for Grants, 1994 – 95

Radical Journal of Health (New Series) Vol.II:1, January-March 1996, pp.86-91

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