A story of poor data, inadequate finances

As the political perspective shifts from the holistic approach that early policy planners advocated, public health is now separate from health services. Public health laid emphasis on nutrition, sanitation and drinking water, all of which have now been relegated to other departments while provision of health services is done by multiple providers, most of whom are private players.

The sums allocated are woefully inadequate. Existing Tribal Sub-Plan (TSP) guidelines put in place by the Planning Commission in 2013 mandate that each State should spend a stipulated amount on tribal population at least in proportion to their population percentage.

The sum of ₹1,60,112 crore is a total of Union and State health budget estimates of 2015-16, in 30 States and Union Territories, that reported tribal population. Tribal population of 8.6 per cent implies ₹15,676 crore, which should anyway be allocated specifically for tribal health by the Centre and States, but in reality is not.

In an analysis of 2012 -13 Budgets by the Tribal Health report, it was revealed that only seven States had allocated money to TSP and none of them had followed the guideline of earmarking funds in proportion to the percentage of Scheduled Tribe (ST) population in the State.

Dr Abhay Bang, Chairman of the Committee, says States almost always indulge in ‘Account Jugglery,’ while showing spending on tribals. Bang says there are ‘dark areas,’ or ‘black holes,’ when it comes to funding for tribal areas.

Various ministries show under TSP, the regular services that they would in any case have to provide in tribal areas. The additional expenditure in these areas remains unstated. Also, there is no consolidated data available on TSP expenditure, at State and Central level,” Dr Bang explains.

In States where TSP was charted out, little has changed as allocations were mostly ‘notional,’ the report says. “The provision has not been effective in improving the status of the tribal population because it has been reduced to an exercise in notional allocation at the time of the budget presentation,” the report starkly states. Ideally TSP expenditure should not be ‘notional,’ but ‘additional.’ This means that an additional ₹1,507 per capita should be allocated for a population of 10.4 crore tribals. Overall government per capita expenditure on health on entire population is ₹1,277. The report calculates that after deducting expected TSP allocation, it amounts to ₹940 per capita for tribals in routine spending.

Dr Bang argues that per capita tribal health allocation should be per capita health expenditure in the country (minus TSP allocation) and per capita allocation for tribal health as per TSP. “This is (₹940 + ₹1507) equal to ₹2,447 per capita per ST per year,” he says.

“Interestingly if 2.5 per cent of country’s GDP is spent on health, as per the National Health Policy (2016), the overall expenditure on health would be ₹3,39,400 crore which comes up to ₹2707 per capita. Thus under the current circumstances, following the TSP guidelines will ensure that at least for the tribal population, the health expenditure is in tandem with the National Health Policy and recommendations of various committees,” the report states.

“It took us four-and-a-half years to arrive at the report because there was an astounding silence around the issue of tribal health. Everywhere it was assumed that tribal people are rural people, but tribal people are different, because they inhabit forest and/or hilly areas which are scattered across vast geographies,” says Dr Bang.

He adds that tribals are more remote and hence their problems compounded. “No estimate was separately available for the tribal people in NFHS data. The Indian Institute of Population Sciences (IIPS) had to re-analyse the NFHS data by filters of scheduled tribes, as the families interviewed for NFHS had their castes and other details recorded,” he states. Manoj Jhalani, Additional Secretary, Union Health Ministry, who is also the Member Secretary of the Expert Committee, adds, “Under National Health Mission, there is no special scheme for tribal areas, and public health being a State subject, the primary responsibility for providing quality health services to the population including those in tribal areas is that of the State governments. However, in NHM we have given a special emphasis on tribal health.”

“But then again, education, nutrition, housing, health and water are competing priorities. In a country, where we have burgeoning population and scarce resources, one-on-one attention to each person is difficult to achieve,” says the official. The original approach of locating public health in poverty and malnutrition has been forgotten.

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