Context

• The Fifteenth Finance Commission health grant constituting the urban share which is nearly five-fold that of the annual budget for the National Urban Health Mission and rural allocation is one-and-a-half-fold that of the total health spending by Rural Local Bodies in India is an unprecedented opportunity to fulfil the mandate provided under the two Constitutional Amendments, in 1992.

Mandate under constitution

• The 73rd and 74th Constitutional Amendments of 1992 mandated the local bodies (LBs) in the rural (Panchayati raj institutions) and urban (corporations and councils) areas to take the responsibility to deliver primary care and public health services. 
• Expected outcome: Greater attention to and the allocation of funds for health services in the geographical jurisdiction of the local bodies.

Why does the 15th Finance commission grant sound important?

• The allocation in FY 2021-22 would be 2.3% of the total health expenditure (both public and private spending together), 5.7% of the annual government health expenditure (Union and State combined), 18.5% of the budget allocation of the Union Department of Health and Family Welfare for FY 2021-22 and around 55% of the second COVID-19 emergency response package announced in July 2021. 
• Yet, it is arguably the single most significant health allocation in this financial year with the potential to have a far greater impact on health services in India in the years ahead.
• Because in 2017-18 the ULBs and RLBs in India were contributing 1.3% and 1% of the annual total health expenditure in India. Both urban and rural India need more health services; however, the challenge in rural areas is the poor functioning of available primary health-care facilities while in urban areas, it is the shortage of primary health-care infrastructure and services both.

Problem with Local bodies dealing with health

Poor infrastructure

• Urban India has just a sixth of primary health centres in comparison to rural areas even though it has just half of the rural population.

Insufficient funding

• Insufficient funding for health is further compounded by the lack of coordination between a multitude of agencies which are responsible for different types of health services
  • For example, a few reports of three municipal corporations in Delhi refused to allocate land for the construction of mohalla clinics (an initiative of the State Health Department) and even the demolition of some of the under-construction clinics.

Unwilling to increase health spending

• The government funding for urban primary health services was not channelled through the State Health Department and the ULBs (which fall under different departments/systems in various States) did not make a commensurate increase in allocation for health. The reasons included 
  • Resource crunch 
  • Lack of clarity on responsibilities related to health services
  • Completely different spending priorities.

Essential steps

Sensitise key stakeholders

• The grant should be used as an opportunity to sensitise key stakeholders in local bodies, including the elected representatives (councillors and Panchayati raj institution representatives) and the administrators, on the role and responsibilities in the delivery of primary care and public health services. 

Enable accountability

• Awareness of citizens about the responsibilities of local bodies in health-care services should be raised. 

Raise awareness 

• Civil society organisations need to play a greater role in raising awareness about the role of Local Bodies in health, and possibly in developing local dashboards to track the progress made in health initiatives. 

Increase health spending

• The Fifteenth Finance Commission health grants should not be treated as a ‘replacement’ for health spending by the local bodies, which should alongside increase their own health spending regularly to make a meaningful impact. 

Better coordination

• Mechanisms for better coordination among multiple agencies working in rural and urban areas should be institutionalised. 
• Time-bound and coordinated action plans with measurable indicators and road maps need to be developed. 

Develop innovative health models

• The young administrators in charge of such RLBs and ULBs and the motivated councillors and Panchayati raj institution members need to grab this opportunity to develop innovative health models.

Need of the hour

• India’s health system needs more government funding for health. However, when it comes to local bodies, this has to be a blend of 
  • Incremental financial allocations supplemented by elected representatives showing health leadership
  • Multiple agencies coordinating with each other
  • Increased citizen engagement in health
  • The setting up of accountability mechanisms and guiding the process under a multidisciplinary group of technical and health experts. 

Conclusion

• The Fifteenth Finance Commission health grant has the potential to create a health ecosystem which can serve as a springboard to mainstream health in the work of rural and urban local bodies and the Indian health-care system should make use of this in the right direction.

Reference:

1. https://www.thehindu.com/opinion/lead/small-grant-but-a-big-opportunity-for-local-bodies/article37778293.ece