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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