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State Level Convention on Health Sector Budget in Orissa: Demands for a Change
Organized by CEHAT, HRLN, BGVS-JSA, NSA CIVIL SOCIETY CHARTER OF DEMANDS ON BUDGET FOR BETTER HEALTH OUTCOMES Compiled by Network for Social Accountability (NSA) On the basis of Suggestions received from Civil Society Practitioners and Common Citizens For discussion and approval in State Level Convention on Health Sector Budget in Orissa: Demands for a Change
Organized by CEHAT, HRLN, BGVS-JSA, NSA
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CIVIL SOCIETY CHARTER OF DEMANDS ON HEALTH BUDGETING
(I) Overall Demands on Health Sector Budget in Orissa
· It has been observed that the share of budgetary expenditure on health and family welfare in the total state budget is on consistent decline. As a percentage of total state budget, the share of health has gone down from around 5 percent in 1995-96 to around 3 percent (annual average) during the last five years. The Civil Society takes serious note of this and urges that Public expenditure on health as percentage of total budget should be doubled in 2009-10 budget and subsequent years. As a percentage of GSDP, it should be stepped up to at least 3% from less than 1 % of GSDP at present. · It has been observed that even the low level of allocation on health and family welfare is not realized. There are huge gaps between budgeted allocations and actual expenditure. Again, such gap is observed more in case of non plan expenditure. This year also, as revealed by media, the government is planning for a massive reduction in the non plan expenditure on health and family welfare of the forth coming budget. Civil society takes serious note of such under utilization and non allocations for health services. It should be kept in mind that even Rs. 1 crore of allocations on health that remains unutilized has a huge opportunity cost of treating and saving hundreds of lives of our ailing mothers, children and poor brothers and sisters. The civil society demands that the concerned authorities should be vigilant enough to check under utilization/ miss utilization of public resources. · There is huge regional disparity in health outcomes in Orissa. In the coastal areas the problem of public health services largely lies with under utilization. But in the western part of the state the problem is largely with non allocation and continual apathy. It should be kept in mind that such regional disparity and apathy towards people living in different parts of the State is a gross undermining of the democratic ethos promoted by our Constitution. Civil society urges upon the government planning authority to take serious action for removing regional imbalance and for maintaining inter-district equity while making provisions for health services. · It has been observed that a large part of expenditure on health goes towards salary. However during last few years there is a marked declined in the share of salary in total expenditure. Given the fact that government health sector in Orissa is at least four times more under-staffed compared to the all India average, there is a need for increasing the personnel strength in the department of health. The civil society demands that all vacancies in the health sector (especially, doctors) should be filled up without delay. · The present ruling party had promised in its election manifesto 2009 that efforts shall be made to provide one full fledged hospital for 5000 families. However currently there is only one hospital level institution for around 45000 families in the State. If one takes the electoral promises made in the BJD manifesto seriously then the State needs around 1500 more hospitals over and above the existing 181 hospitals in the state. This calls for a massive capital investment in the health sector. Unfortunatly the capital expenditure is one of the least bothered head in our health budget. As a percentage of total expenditure in the health and family welfare budget, the capital expenditure has gone down from around 3.44 percent in 2005-06 to 0.2 percent in 2008-09 BE. Even with a very conservative estimate of Rs. 50 lakh per hospital the capital expenditure required additionally would be around Rs. 750 crore (Approx.). With the average per health institution cost of Rs. 1.8 lakh for running the system, it would mean an annual additional expenditure of around Rs. 25 crore, excluding the salary of the medical staff. Given the extremely backward and low starting point and an astronomically high unmet need, such a level of investment is desirable. The civil society urges upon the present government to fulfill its own promise of providing one hospital for 5000 families at the earliest · It has been observed by the Civil Society that there has been a large scale urbalisation of health services in Orissa. While the proportion of total expenditure on urban health services has gone up from around 18 percent in 2005-06 to 34 percent in 2008-09 BE, the same on rural health services has gone down from around from more than 41 percent in to 31 percent during the same period. As per the population census figures, around 85 percent of the total population still live in rural areas. In this context, the civil society demands that the primary focus of the government health provisioning should be on rural areas in the state. · Often poorer states find it difficult to provide matching grants for centrally sponsored schemes, due their limited resource mobilization capacity. Orissa is no exception to this phenomenon. The provision of matching grants in the centrally sponsored schemes should be abolished with immediate effect. The civil society urges upon the government of Orissa to take appropriate steps to bargain with the government of India for more autonomy and abolition of the concept of matching grants in the CSS which is discriminatory against the poorer states like Orissa. The civil society promises to support the state government in this regards in all possible ways to take forward this effort to restore our federal structure. · The government should take every effort to check the unbridled growth of the private players in the health services sector. · Instead of making provisions for basic health services, the government is trying to address the issues of public health through systems of insurance. While insurances are welcome, it can not be treated as a substitute for basic health facilities. Orissa is a place where people die of very ordinary ailments as proper care facilities are not available nearby. Many common ailments for which a person has to spend money are not covered under insurance systems. Civil Society demands that the government should work beyond making such provisions like insurance and improve the fundamental health system itself. · There should be a Primary Health Centre for each Gram Panchayat with adequate facilities to provide health services to people at door step. Government should ensure that a doctor is available in the hospital campus throughout the day and night.
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· There should be a provision for Revolving fund support to each self help group (SHG) in the state for establishment of Community Based Drug (CBD) Centers. Training to the leaders of the self help groups as community doctors who must have knowledge on the use of common medicines as well as providing basic and primary health care services in case of emergency. Organization of regular health camps in the unserved areas with regular checking of the CBD centers by the doctors attending the health camps will be very helpful. The Civil Society demands that the SHGs be mobilized towards creating health awareness and health support at the level they are operating. · The Civil Society urges the Government of Orissa to take a proactive role in providing self appraisal reports on its performance in achieving the outcome targets for improving the health situation in Orissa. The government may set its own targets on health outcomes but the targets set in the Millennium Development Goals (MDGs) should be taken as minimums that our governments are already committed to. Annual rolling targets must be set for making assessment on the progress towards the MDGs in health sector in Orissa. The achievements and hurdles should be made public for wider awareness on the issues.
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· In a State like Orissa, mobile medical vans are currently more useful for providing access to healthcare in remote areas, reserve forest and sanctuary areas and other protected areas where availability of doctors, communication to the hospitals are pertinent issues. It is in this context that the civil society demands for making provisions for additional mobile health units in the State. Currently, there are only 14 Mobile Health Units (MHU) in the State. The civil society demands that the number of mobile health units be raised to 314 over next few years in order to maintain one MHU in each block. In fact, this was a promise made in the BJD Manifesto during elections. The civil society demands that on an urgent basis, at least 139 new MHUs should be provided to the specific districts with immediate effect and the rest can subsequently be provided during the five year rule of the present government.. The districts that need immediate attention for Mobile health units are as described in the table below.
· It has been considered by the civil society that in the context of prevalent diseases in Orissa, even non-specialist doctors and health workers are extremely useful in many areas. A cadre of rural doctors may be trained and developed to provide health services in many common diseases. While it is understood that the non-specialist doctors can not work as substitutes to doctors in the state, given the urgent necessity of doctors in the state, it is deemed that such a process be developed in true spirit. · Efforts should be taken to improve the quality of traditional health practitioners with scientific medicine and scientific knowledge about diseases and their remedy. · In proper coordination with the Department of Higher education, efforts should be made to provide compulsory foundation courses and ancillary courses in primary health care at the Graduation level for all students. Course materials should be developed by professionals, experts, artists and language specialists in a manner that those are comprehendible even for the students coming from arts and commerce streams. This, the civil society believes will bring in scientific approach towards health care among the masses in rural areas and shall be helpful in solving many related issues which do not necessarily need intervention of specialist doctors. · The medical education system in the state should be reformed in a manner that money does not remain as a criterion for admission, even in private medical colleges. The amount of money being charged currently in Orissa for medical education is forbiddingly exorbitant in Orissa and this need to be checked with immediate effect. The system of management seats for admission should be abolished. All the students enrolled in medical colleges including private medical colleges should be selected through common entrance system (with all respect to the constitutional provisions for reservations) and the cost of imparting medical education in private institutions should be provided by the government through subsidy instead of being collected from the students in the form of fees. · More government colleges are built in the state for providing medical education in the state. · The civil society makes a case for taking strong action against the spread of fake medicines in the state. · Specific budgetary allocation should be made to build awareness and sensitization of the health workers on dealing with HIV+ people.
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II. Demands Specific to Women
o Like any other state in the country, the socio-political structure and the policy making paradigm in Orissa is influenced by the chains of servitude, patriarchy, mass poverty and low awareness among the masses. This leaves limited space for policy making process to be sensitive towards the issues of the marginalized sections of our population including, women, children and the aged. The civil society urges upon the state government that the policy making in general and health related planning in particular should be made more gender sensitive by ensuring representative participation of the concerned entities, such as gender rights groups, womens studies centres and the section of civil society that works consistently on issues related to women. o In order to check the declining sex ratio in the state, strict action is required against sex determination of the fetus. There is also a need to wage a battle at the level of awareness building of the masses for stopping sex determination of the fetus. Civil society demands that a special cell should be formed in the department of health and family welfare with qualified doctors, representatives of teachers and legal experts to initiate a mass campaign against sex-determination. o In the light of the above, the civil society demands for strict implementation of Pre-Conception and Pre-Natal Diagnostic Techniques Act 1994 (PC & PNDT Act) in all the districts of Orissa, Adequate provisions should be made for capacity building, awareness creation, engagement with civil society and women’s organizations etc. Specific allocations should be made for the enforcement of Pc & PNDT Act. o Adequate allocations should be made for programmes related to child survival and safe motherhood. There is a need for increasing the number and quality of local dhais/TBAs through a massive training programme in the state. Adequate funding should be provided for the purpose. o It is quite disappointing to note that the women specific programmes running in the state do not have any non plan component. This put serious question marks on the intentions and commitments of the state government on women specific issues related to health. Again, the total allocation on women specific programmes is so small that even with a quantum jump over the previous year allocation, it was only Rs. 15 crore for the whole state in 2006-07. The civil society demands that at least 30 percent of all expenditure under the ministry of health and family welfare be earmarked for women beneficiaries and for improving the health situation of the women. Monitorable indicators of progress should be evolved for the purpose. o The Civil Society demands that an update on the progress on the implementation of Women Component planning with the health sector shall be made public through the government website, news papers and other media. There should not be any further delay in institutionalizing the women component plan with the health sector. o Women related schemes like JSY have a lot of potential in promoting institutional delivery. However, in Orissa such schemes are marred by rampant corruption and appropriation of beneficiary money by the service providers in a very systemic manner. Corruption in the programme delivery level be checked by strengthening the institutions of Gan Kalyan Samiti. Adequate provisions should be made for the purpose.
III. Demands Specific to Dalits and Adivasis
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o In the recent years public expenditure on welfare of dalits, adivasis and other backward classes has fallen. The government should reverse this trend in the forthcoming budget. As far as health sector is concerned, many specific diseases like sickle cell, malaria etc, which are more prevalent in tribal areas should be given adequate attention. o As per the norms of Scheduled Caste Sub Plan and Tribal Sub Plan, at least 39 percent of the total allocations for the public health sector should be earmarked for the targeted benefits of the SC and ST sections in Orissa. o Sufficient care should be taken to ensure that students from marginalized sections such as SCs and STs get an opportunity to get enrolled for medical education.
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