District fund flow under National Rural Health Mission and service delivery: some insights from Karnataka - K. Gayithri

District fund flow under NRHM District fund flow under NRHM and service delivery: some and service delivery: some

insights from Karnatakainsights from KarnatakaDr.K.GayithriDr.K.Gayithri

Institute for Social and Economic Institute for Social and Economic Change,Change,

BangaloreBangalore

BackgroundBackground A part of a broader study that aimed at :

- Developing a comprehensive picture of funds flows across all levels of healthcare services (state – district – block – individual health facilities), within the framework of “district health system”, which the NRHM aims at strengthening and empowering.

To track the district level funds flow and expenditure, 2 districts, which are representative of the variations expected in the healthcare provisioning in the state under study were selected- Gulbarga and Chitradurga.

Within each district sample of 1district hospital, 2 block level hospitals/FRUs, and 8 PHCs and sub centers, were selected in consultation with the state and district officials.

Structure of presentationStructure of presentation

State level NRHM funding: Whither need based planning?

District level fund distribution under NRHM: Karnataka Case

Select districts: fund flows; Fund decentralization major cost drivers

Fund predictability Issues of concern and policy

intervention

NRHM: PIP; Release; NRHM: PIP; Release; ExpenditureExpenditure

PIP allocations do not get completely translated into releases and releases in turn are not completely spent.

Fund underutilization even while there are complaints of fund shortage is a clear anomaly

NRHM: PIP; Release; Expenditure NRHM: PIP; Release; Expenditure percentagespercentages

NRHM funds: District wise share and per NRHM funds: District wise share and per capita expenditurecapita expenditure

While the share of expenditure to a

large extent reflects the need of the

region going by its backwardness, they are clearly

getting lesser funds in terms of per capita

funding

Head

Chitradurga Gulbarga

2008-09 2009-10 Growth rate 2008-09 2009-10 Growth rate

RCH

294.67

(38.79)

368.71

(44.07)

25.13 797.93

(52.83)

613.96

(40.53)

-23.06

NRHM Additionalities

354.13

(46.61)

359.43

(42.96)

1.50 533.01

(35.29)

787.96

(52.01)

47.83

RI & DCP

110.91

(14.60)

108.56

(12.97)

-2.12 179.53

(11.89)

113.02

(7.46)

-37.05

Total 759.71 836.72 10.14 1510.47 1514.95 0.30

NRHM expenditure in the study NRHM expenditure in the study districts*districts*

(Rupees in Lakhs)(Rupees in Lakhs)

Exp pattern in Gulbarga- A cause for concern An abs. decline in allocation Towards RCH,DCP And a sharp increase In NRHM additionalities -Chitradurga has a larger increase

Per Capita Per Capita ExpenditureExpenditure

Head Chitradurga Gulbarga

2008-09

RCH 17.27 21.74

NRHM 20.76 14.52

RI & DCP 6.50 4.89

Total 44.53 41.15

2009-10

RCH 21.29 16.39

NRHM 20.75 21.03

DCP 6.27 3.02

Total 48.31 40.44

*Per capita expenditure pertains to the entire district Source: District Financial Abstract Prepare by District Program Management Unit

Total funds and Fund DecentralizationTotal funds and Fund Decentralization Health Expenditure Health Expenditure (Rupees in Lakhs)(Rupees in Lakhs)

Health sector funds are predominantly from the treasury route in both the districts. Share of district hospital is much larger in Gulbarga as Compared to that of Chitradurga- also seems to have better Fund Decentralization

Facilities Chitradurga Gulbarga Treasury NRHM Total Treasury NRHM Total

DHO 579.08

(12.99)

NA 579.08

(12.99)

434.39

(7.74)

NA 434.39

(7.74)

District Hospital 2050.97

(46.02)

25.29

(0.57)

2076.26

(46.58)

3530.82

(62.93)

23.23

(0.41)

3554.05

(63.34)

Taluk Hospital 633.21

(14.21)

17.88

(0.40)

651.09

(14.61)

562.54

(10.03)

19.94

(0.36)

582.48

(10.38)

CHCs 470.93

(10.57)

20.85

(0.47)

491.78

(11.03)

393.89

(7.02)

39.03

(0.70)

432.92

(7.72)

PHCs 478.98

(10.75)

46.45

(1.04)

525.43

(11.79)

483.15

(8.61)

60.64

(1.08)

543.79

(9.69)

SCs 127.47

(2.86)

6.30

(0.14)

133.77

(3.00)

62.40

(1.11)

0.80

(0.01)

63.20

(1.13)

Total 4340.64

(97.38)

116.77

(2.62)

4457.41

(100)

5467.19

(97.44)

143.64

(2.56)

5610.83

(100)

Major cost driversMajor cost drivers

Facilities

Chitradurga Gulbarga

Treasury NRHM Treasury NRHM

Salary Non Salary

Salary Non Salary

Salary Non Salary

Salary Non Salar

y

DHO 8.86 4.13 0.00 0.00 5.44 2.30 0.00 0.00

District Hospitals

42.19 3.82 0.05 0.51 56.89 6.04 0.00 0.41

Taluk Hospitals

12.84 1.36 0.07 0.33 9.62 0.41 0.12 0.24

CHCs 9.76 0.80 0.05 0.41 6.88 0.14 0.28 0.41

PHCs 10.47 0.28 0.35 0.69 8.39 0.22 0.47 0.61

SCs 2.82 0.04 0.00 0.14 1.06 0.05 0.00 0.01

Total 86.94 10.44 0.53 2.09 88.28 9.16 0.87 1.69

Staff strengthStaff strength

Sanctioned and working positions at Group C level is higher in Gulbarga than Chitradurga

For every Doctor Chitradurga DH Has 1.74 Group C officers- Gulbarga has 5.62

Staff Position of District Hospitals

Designation

Chitradurga Gulbarga

Sanctioned

Working Vacant

Sanctioned

Working

Vacant

Group A 28 23 5 49 39 10

Group B 15 4 11 10 5 5

Group C 103 40 63 289 219 70

Group D 148 75 73 255 118 137

Total 294 142 152 603 381 222

Poor alignment of releases and Poor alignment of releases and expenditureexpenditure

RCH 2 fund received and spent by Distict Hospital Gulbarga

0

200000

400000

600000

800000

1000000

1200000

2007-08 2008-09 2009-10

Year

Ru

pees i

n L

akh

Received

Spent

NRHM fund Received and Spent by Jewargi Taluka

0

100000

200000

300000

400000

500000

2007-08 2008-09 2009-10

Year

Am

ou

nt

Ru

pee

s

Received

Spent

NRHM funds Received and Spent by Sedam

0

100000

200000

300000

400000

500000

2007-08 2008-09 2009-10

Year

Am

oun

t R

upee

s

Received

Spent

Complete mismatch between release and expenditure at all the facility levels

Receipt and Expenditure of NRHM Receipt and Expenditure of NRHM Funds by District Hospital, GulbargaFunds by District Hospital, Gulbarga

Programme 2007-08 2008-09 2009-10 Received Spent Received Spent Received Spent Balance

I. RCH 2 165000 0 150000 228640 1000000 520980 488580 Of which JSY 150000

(in Mar 08) 0 50000

(in March 09)

136800 400000 401400

Family Welfare

100000 91840 300000 (2lakh in

Dec)

109580 198580

Thai Bhagya

15000 (in Mar 08)

Prasoothi Arike

(Started in Aug. 2009) 300000 10000 290000

II. NRHM Addl. (untied funds)

1000000 (Opening Balance as

on 01-04-08)

500000 0 0 1485920

14080

Total (I+II) 650000 228640 1000000 2006900

502660

Fund Predictability and bunching of Fund Predictability and bunching of expenditureexpenditure

Funds received by each sub center at varied points of time.

Funds received at the fag end of the financial year.

Instances of fund disbursal after the lapse of the financial year

Policy correctivesPolicy correctivesPIPS, releases and expenditure to be

better alignedEnhance the planning rigor to better

address the area needs. Population of a region and health needs to serve as a basis in resource allocation

Strict adherence to financial year releases and expenditure, no spillovers

Fund release to be better stream lined and rush of expenditure to be controlled

Maternity benefits reaching beneficiaries much after the event