India’s total spending on health is 4.2 percent of GDP of which public spending on health is just barely above 1 percent. Although the State and Union Governments’ expenditure in absolute terms have increased in the last ten years, from 2004-05 onwards, a stagnation is observed in the Union Governments’ spending on health. Presently, Union and State governments together spends only 1.2 percent of GDP on public healthcare. An increase to 2.5 per cent of GDP by 2017 anticipated in the country’s 12th Five Year Plan, is itself one of the lowest proportions recorded anywhere in the world (Charts 1 & 2). The last ten years trend in budgetary spending both by the Union and State governments clearly indicates that health does not figure adequately in the priority list of the development agenda.
This case study on Maternal Health Budget shows that while for low performing states, the guidelines still have scope for improvement in indicators, in order to meet the targets for attaining globally comparable levels of IMR and MMR, there needs to be changes made in the scheme guidelines for high performing states. This has been an evolving process and has been observed from the changing guidelines to include women delivering at home which has been a major factor for inclusion in JSY. Removal of age restrictions on mothers and restrictions on number of children has also helped in increasing beneficiaries as well as greater utilisation of funds leading to a positive impact on the outcomes. However, maternal and reproductive health of a woman is not only about delivery. It is intrinsically linked to the overall health and nutritional status of a girl child from the time she is born. Thus while JSY is acclaimed as a grand success, ensuring proper food security and secure livelihoods also need to be linked to maternal and reproductive health outcomes.
There have also been several criticisms of the programme. First and foremost the problems linked to exclusion of women in remote rural areas residing in difficult terrains, who find it impossible to commute for delivery at the designated health facilities. While guiding principles for such cases have been included for delivery at home, yet for there needs to be more mobile vans or other modes of mobile delivery facilities which would be able to reach the women on time.
A more recent concern that has been highlighted with regard to increase in institutional deliveries has been about the behavior mooted towards pregnant women in the health centres. This concerns lack of proper infrastructure as well as caste oppression for poor, dalit and adivasi women who are not provided with beds during labour. A lot has been reported about the rough and insensitive behavior in rural areas towards women in labour, to the extent that women have had to be taken to private facilities nearby for better treatment. Studies have pointed towards infrastructural deficiencies in terms of lack of beds and related requirements as well as shortage of human resources creating pressures on the existing staff at the health centre leading to such unwarranted situations.
Apart from this, reports of fund misappropriation by the ASHAs through maintaining false rosters of pregnant women have also come into light under JSY. Such discrepancies point towards a more serious concern about how to treat the health workers who are the foot soldiers of service delivery. While increasing remunerations is an important and viable alternative, improving overall work conditions as well as not overburdening ASHAs with loads of responsibilities is also the need of the hour.
Finally it is also important to note that while a major part of NHM goes for RCH activities, it should not only focus on Institutional deliveries but needs to recognise associated activities related to maternal health and bring it under the fold of RCH activities. Those could well be related to improving infrastructural and human resource needs as well as nutritional needs, quality of care including extension of post natal period of care.
You can access the case study here: 5. Maternal Health – JSY