ResourceTrackingandManagement(RTM):

StateLevelResultsfromBihar

(2007-08to2013-14)

July2017

TheRTMConceptualFramework

ResourceMobilization

Whatisthepotentialforraisingmoreresourcesforhealth?Fromwhere?Whatdeterminestheresourceenvelopeatnationalandsub-nationallevels?

ResourceAllocation

Howarefundsallocatedtodifferentprogramsandfunctionsatnationalandsub-nationallevels?Whatfactorsdeterminetheallocationtoprimarycare?

ResourceUtilization

Aretheallocatedfundsbeingutilized?Whatfactorsdrivesuccessfulbudgetexecution?Whataretheexistingbottlenecks?

ResourceProductivity

Howeffectivelyareresourcesbeingtranslatedintoservices?Isdeliveryefficientandwhatcanbegainedfromefficiencyimprovementsintermsofvolumeandquality?

ResourceTargeting

Areinputsbenefitingtheintendedindividualsandpopulation?Ispublicspendingreachingthepoor?

Methods• Financialdata- Analysisisforyears2007-08to2013-14

• Streamsoffinancinganalyzed

Ø Treasuryroute(Fundspooledbythestatefromgeneraltaxation)

• ExpendituresincurredMajorcodes2210,4210(MedicalandPublicHealth),2211,4211(FamilyWelfare)underDemandforGrantno.20(HealthDepartment)

Ø GOItransfers(toSHS;andstatetreasuryforinfrastructureandmaintenanceforNHM)

Ø GOIOther(Centrallysponsoredschemes)

• BudgetTrackingTooldevelopedbyNHSRCendorsedbytheMOHFWwasusedtoestimateprimarycare.AllofNHMisconsideredprimarycareforthisstudyandanalysis.

IdentifyingPrimaryCareFunding:NHSRCTrackingToolkit

HierarchyLevel

BudgetLines/Heads ExamplewithCode

ExamplewithCode

Level 1 MajorHead MedicalandPublic Health–RevenueExpenditureHead(2210)

Level2 Sub-majorHead

Public HealthHead(06)

Level 3 MinorHead PreventionandControlofDiseases(101)

Level4 Sub-minorhead

NationalTBProgram(04) PRIMARYCARE

Level 5 DetailedHead DrugsandMedicines (60)

SourcesandRoutesTrackedforHealthFundsSource TreasuryRoute SocietyRoute Notes

State(1)

State’sownhealthbudget

(4)State’sshareofNHMbudget

(1) AllocationoftaxrevenuesbytheStateTreasurytohealthandcentralrevenuestransferstostates

(2) ApprovedNHMbudgetbasedonPIPtransferredbyGOItoStatetreasury

(3) GOIcontributiontohealthbudgetforCSS(non-NHM)

(4) Statecontributionof15%andnow25%ofapprovedPIPtransferredfromstatetreasurytoSHS

(5) GOIcontributiontoNHMbudgettransferredtoSHS

Center(GOI)

(2)NHMfundsforinfrastructure &maintenance

(5)GOIshareofNHMbudget

(3)OtherCentrallySponsoredSchemes

StateHealthBudget

10,68214,969 15,235 17,627

24,298 23,69527,2318,493

9,786 12,54712,739

13,45220,371

20,169

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

TotalHealthBudget(inRsmillion)

StateHealthBudget(excludingNHM)* NHM(allroutes)**

147% Total Health Budget:

• Rs 19,174 million (2007-08)

• Rs 47,401 million (2013-14)

• Increase of 147% over 7 years.

NHMasashareofTotalHealthBudget

56% 60% 55% 58% 64% 54% 57%

44% 40% 45% 42% 36% 46% 43%

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14StateHealthBudget(excludingNHM) NHM(allroutes):approvedbudget

Over the last 7 years

• On average NHM has contributed 42% of the THB

• Bihar has among the highest dependency on NHM.

• Share of NHM in the THB was at its highest at 46% in 2012-13,

SGHBandTGHBasashareofGSDP

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14SHB 1.17% 1.13% 1.02% 0.95% 1.08% 0.97% 0.93% THB 1.69% 1.74% 1.71% 1.49% 1.55% 1.50% 1.38%

0.00% 0.20% 0.40% 0.60% 0.80% 1.00% 1.20% 1.40% 1.60% 1.80% 2.00%

• DecliningtrendsinTGHB&SGHBasashareofGSDP,despiteeconomyofthestatewitnessingamongthehighestgrowthtrendinthecountry

• Substantialincreaseindemandforhealthservices- Fourfoldincreaseinpatientfootfallinhospitalsbetween2007-08&2013-14duetobetterinfrastructure– BiharEconomicSurvey,2014-15

ActualGovernmentExpenditureonHealth(Nominal)

INDICATORS 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

Total Health Expenditure for Bihar(in Rs Millions) 14,720 19,439 18,677 23,028 26,898 30,411 34,036

State’s share in THE (in Rs Millions) 12,622(86%)

11,522(59%)

13,294(71%)

14,553(63%)

18,744(70%)

21,203(70%)

22,615(66%)

NHM expenditure (in Rs Millions) 3,826 10,927 7,839 14,186 11,074 13,589 11,936

Per Capita THE (in Rs) 159 207 196 238 274 306 338

Total Primary Care Expenditure (State & NHM)

10,273(70%)

14,109(73%)

12,603(67%)

17,049(74%)

17,586(65%)

20,278(67%)

22,253(65%)

Per Capita Primary Care (in Rs) 111 150 132 176 179 204 221

THE as a percent of State GSDP 1.29 1.37 1.15 1.13 1.11 1.04 0.99

Primary Care Expenditure as percent of State GSDP 0.90% 0.99% 0.77% 0.84% 0.72% 0.69% 0.65%

BiharTotalGovernmentHealthExpenditure

86%

59% 71% 63% 70% 70% 66%

14%

41% 29% 37% 30% 30% 34%

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

Stateshare Centershare

• AverageState’sshareinTGHE:68%

BiharTotalHealthExpenditure(Byroute)

10,894 8,512 10,839 8,842

15,825 16,82222,100

3,826 10,927 7,839 14,186

11,07413,589

11,936

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

State(NonNHM) NHM

Increaseinexpenditure:131%over7years.Increaseinbudget:147%.

AnnualGrowthRateinTotalGovt.HealthExpenditure(bySourceofFinancing)

2008-09 2009-10 2010-11 2011-12 2012-13 2013-14Stateshare -8.71% 15.38% 9.47% 28.80% 13.12% 6.66% Centershare 277.29% -32.00% 57.42% -3.79% 12.93% 24.03% THE 32.06% -3.92% 23.29% 16.81% 13.06% 11.92%

-50% 0%

50% 100% 150% 200%250% 300%

AnnualGrowthRateinHealthExpenditurebySources

Stateshare Centershare THE

TotalGovernmentPerCapitaExpenditureinBihar

136 122 139 150191 213 225

2384 56

88

8393

113

159

207196

238274

306

338

-

50

100

150

200

250

300

350

400

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

PercapitaStateHealthExpenditure PercapitaGoIexpenditureonhealth PercapitaTotalHealthExpenditure

Per capita health expenditure one of the lowest in the country

BiharHealthExpendituresbyLevelsofCare(TreasuryOnly)inRs.Million

AllocationsbyLevelsofCare 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

PrimaryCare 9,423(68%)

7,575(59%)

9,009(60%)

10,693(64%)

11,933(56%)

13,851(58%)

13,954(54%)

SecondaryCare 1,603 1,831 1,852 1,673 2,976 3,342 3,752

TertiaryCare 1,189 1,767 1,936 2,083 2,555 2,536 2,785

MedicalEducation 1,286 1,358 1,734 1,994 3,077 3,341 4,613

Administration 370 375 552 229 705 914 633

Total 13,870 12,906 15,083 16,672 21,246 23,984 25,736

PerCapitaPrimary(Rs.) 82 68 71 100 91 99 102PerCapitaPrimary(incl. NHM)(Rs.) 110 149 131 176 179 203 220

BiharExpenditurebyLevelsofCare(TreasuryOnly- 7yearsaverage)

2007-08to2013-14

Primary care 59%

Secondary care 13%

Tertiary care 12%

Medical Education

13%

Administration 3%

Largest share (59%) of the health expenditure through Treasury route is on Primary Care

ComparingGrowthRates:TotalGovt.PrimaryHealthExp.(TGPHE)&TotalGovt.HealthExpenditure(TGHE)

-20%

19% 19% 12%

16%

1%

-7%

17% 11%

27%

13% 7%

-30%

-20%

-10%

0%

10%

20%

30%

2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

ComparinggrowthrateofTGPHE&TGHE

TPCEgrowthrate THEgrowthrate

ExpenditureAllocationbyTypesofInputs(TreasuryOnly)

0% 10% 20% 30% 40% 50% 60% 70% 80%

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

HumanResource OperatingCost* Drugs&Pharmaceuticals

CapitalProjects Others**

• HR comprises highest share of expenditure

• Drugs, pharmaceuticals & consumables range between 5% to 5.5% across all the 7 years

ExpenditureAllocationbyTypesofInputs(NHMthroughStateHealthSocietyonly)

Programs/Othersinclude:Trainings,Servicedelivery,incentives,untiedfunds,IEC/BCC,monitoringandallothercostsrelatedtoservicedeliveryandprogramimplementationunderdifferentcomponentsofNHM

AreaswhereNHMhasbeenabletomakeanimpactonexpenditure:

• Program/servicedeliverycosts

• Drugs,pharmaceuticals&consumables

UtilizationRatesforTreasuryBudgets(ExpenditureinRs.Million)

UtilizationRate 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

HealthBudget(Treasury) 13,316 17,588 18,151 21,175 28,438 31,027 34,481

HealthExpenditure(Treasury)

13,870 12,906 15,083 16,672 21,246 23,984 25,736

HealthExpenditureagainstbudget*

104.17% 73.38% 83.1% 78.73% 74.71% 77.3% 74.64%

UtilizationRatesforNHM(ExpenditureinRs.Million)

UtilizationRate 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

TotalNHMApprovedbudget 8,493 9,786 12,547 12,739 13,452 20,371 20,169

TotalfundsavailableundertheNHMScheme(opening balance,interest,fundstransferredduringtheyear)

8577 17,388 17,642 20,931 22,899 33,423 30,880

TotalExpenditureIncurred 3,826 10,927 7,839 14,186 11,074 13,589 11,936

UtilizationagainstapprovedbudgetforNHM– (ENTIRESCHEME)– allroutes:TotalExpenditure/totalapprovedbudget

45.05% 111.66% 62.47% 111.35% 82.32% 66.71% 59.18%

UtilizationagainstfundsavailableforNHM– (ENTIRESCHEME)– allroutes:TotalExpenditure/totalfundsavailable

44.61% 62.84% 44.43% 67.77% 48.36% 40.66% 38.65%

NHM(SHS)underutilization– IMPACT

• IfSHSspends100%offundsavailable,increaseinTGHE:

• Bihar:49%

• UP:26%34,036

1,19,650

50,595

1,50,370

-

20,000

40,000

60,000

80,000

1,00,000

1,20,000

1,40,000

1,60,000

Bihar2013-14 UP2014-15

TGHE(inm

illionRs.)

ImpactofStateHealthSocietyU;liza;ononTotalGovernmentHealthExpenditure(TGHE)

CurrentTGHE TGHEifSHSspent100%

Reasonsforunderspending:CapacityandOperationalissues

NHMsystemdesignandhumancapacityfactors:

• Lackofleadershiptoconceiveandimplementaninnovation

• Riskaverseattitudesofthemanager

• Powerdynamicsatthelocallevel

• Capacitytoprocure(civil,medicines,HR)

• Lackofproperknowledgeofspendingguidelines

Wherethepurposeoftheexpendituresisexplicit:Betterutilizationrates; fore.g.-salaries,drugs

Budgetlinesthatrequirediscretionintheoptimaluseoffunds–utilizationislower,fore.g.- untiedgrants,MFP.

Reasonsforunderspending:CapacityandOperationalissues

Otherkeyoperationalreasons:

• DelaysinapprovalofplansfromGOI

• Consequentdelaysinreleasesoffunds

• Substantialprocurementdelays

• HRvacancies

• CAGauditteamin2013foundmorethan600JSYbeneficiarycheckslyingundeliveredfromthepreviousyear(2012).Reasonsfordelaysincludedelaysinreceiptoffundsandseveralbeneficiarieswithoutabankaccount.

Limitedleadershipcapacitytoconceiveandimplementinnovations:MissionFlexipool

42% 45%

7% 6%

63%

32%

106%

53%

RCHFlexipool MissionFlexipool Immunization&PP DiseaseControl

Budgetshares&utilizationbyNHMProgramComponentsMean(2011-12to2013-14)

Budgetshare BudgetUtilization

NHMflexipoolutilizationisconsistentlylow(includescorpusgrants,untiedgrantsetc);UP– Utilizationofimmunizationprogramishigh– expenditureonexplicitbudgetitems– vaccinesVerylowspendingondiseasecontrol– onlyhalfthefundsspentoutofanalreadyverylowbudget

51%

36%

8% 5%

69%

46%

59%

45%

RCHFlexiPool MissionFlexiPool Immunization&PP DiseaseControl

Budgetshares&utilizationbyNHMProgramComponentsMean(2011-12to2013-14)

Budgetshare BudgetUilization

UTTARPRADESHBIHAR

Limited leadership capacity to conceive and implement innovations: Mission Flexipool

DelaysinCivilWorks– lackofcapacity(Capacity&OperationalIssue)

§ Only5outof298constructionworkcouldbecompletedbetween2011&2015

§ 35areincompleteand258projectswereyettostarteventhoughSHSBtransferringRs.4461.7milliontotheBiharMedicalServicesandInfrastructureCorporation(BMSIC)betweenApril2011&February2014.

§ Utilizationofbudgetallocatedfornewconstruction/renovation:39%(2011-12),7%(2012-13and2013-14)

Limitedmedicineprocurementcapacity(Capacity&OperationalIssue)

§ Delaysinsupplyofdrugswerewidespread- delaysbasedonauditreports :

o 418daysinMadhubanidistrict,337daysinGayadistrict

o 168daysinEastChamparan,165daysinKishanganj

SomePolicyImplications

1)Consideralternateorinnovativemeansoffinancingpharmaceuticalexpenditure(ResourceProductivity):

• Buyinggenericdrugs

• Eliminatesupplier(middlemen)andbuydirectlyfrommanufacturers

• Poolingoffunds

2)Separatetreatmentofexpenditureunitsforreleaseoffundstoimproveutilizationoffunds(ResourceUtilization):

• Treatingtheexpenditureunitsindependentlywillenableallthoseunits,thatareabletospendthefundstimely,receivetherequiredfundspromptlywithouthavingtowaitforUtilizationCertificates(UCs)tobeaggregatedateachlevel(PHC/Block/Districtlevel).

SomePolicyImplications(ResourceUtilization)

3)Delinkthecapitalexpendituresfromroutineexpenditures.(ResourceUtilization)• A separationcouldfreetheroutinefundsflowfromthegettingblocked

byunspentbalancesundercapitalworksandprocurement.4)Improveexistingauditingprocessestoencourageinnovation.(ResourceUtilization)• Thecurrentapproachoffinancialauditneedstoshiftfromchecking

“compliancetoguidelinesanddirectives”to“demonstratingtransparencyandpositiveoutputs/outcome”.

• TheconcurrentauditscanaccommodatethisnewanglebymodifyingtheTORsofsuchauditorsappointedbytheStateHealthSociety.

PolicyImplications

5)Reconsidertheresourceinputallocationnormstoimprovehealthservicedeliveryoutputs• RedesigningtheexistinginstitutionalstructureandHRallocationnorms,given

Bihar’slessdevelopedinfrastructure,shouldbeconsidered.Redesigncouldbebasednotonlyonadministrativelevelandpopulationbutalsoonanelementthattakesintoaccountthe“time”toaccesshealthcare.

DataSources– RTMBihar

1. AuditedbalancesheetsofNHMfrom2007-08to2013-142. WebsiteoftheNHM,GovernmentofIndia:https://nrhm-

mis.nic.in/SitePages/Home.aspx3. PIPsandROPsofNHM4. FMRsofNHMatthestatelevel5. NHMStateProjectImplementationPlansforthestudyyears6. BudgetBooks– GovernmentofBihar7. Census2011,GovernmentofIndia8. PlanningCommission:http://planningcommission.gov.in9. ReserveBankofIndia:https://www.rbi.org.in10. WebsiteoftheMinistryofStatistics&ProgrammeImplementation,

GovernmentofIndia:http://mospi.nic.in/Mospi_New/site/home.aspx11. BiharEconomicSurvey,2014-15