VI - HEALTH AND ENVIRONMENT

Resource Allocation and Infrastructure Development

The ability to avoid exposure to disease or to treat it depends among other things on environmental conditions and health services, including such factors as access to safe water, housing conditions and sanitation. In this section, we consider trends in the allocation of resources for the social services of health, education and welfare, including a description of infrastructural development and access to water, sanitation systems and housing.

Resource Allocation and Infrastructure Development

Immunization coverage
Shelter, sanitation and water supply

Financial outlays under the different five-year plans indicate that investment in the social sector is inadequate. In addition, such investment that has been made has been concentrated on building up service infrastructure. Table 12 shows the per capita expenditure at current (not constant) prices on social services for successive five-year plans, along with the trends in the percentage share of total outlays by sector, while Figure 16 shows the trend in real expenditures, at constant 1987 US dollars (according to successive IMF Financial Statistics Yearbooks). Clearly, there has been little overall improvement in absolute or relative allocations for either health or education, with both remaining at low levels, as compared to other developing countries. As a percentage of total plan outlay, the shares for education and health are significantly lower in the seventh than in the first plan. Even within the education and health sectors, allocations for elementary education and primary health care have declined relative to higher education and curative care respectively.

Figure 16. Per capita expenditure - Constant 1987 US $

Source: IMF Financial Statistics Yearbooks

As Table 12 shows, 1.9% of the total 1985-90 plan outlay was allocated to health care. In 1990, according to the World Development Report (World Bank 1992), 1.6% government expenditure was allocated to health. Of the countries supplying data for this year, only Zaire, Indonesia and Peru allocated proportionately less. When considered in terms of the proportion of overall GNP allocated to health, the picture is even more dismal, owing to the fact that total government expenditure is itself very low in relation to GNP (only 18.2% GNP in 1990). Thus, for 1990, less than 0.3% GNP was allocated to the health sector.

Furthermore, the structure of expenditure has been biased towards urban areas and away from primary health care. The order of priority has been family planning, hospitals and dispensaries, communicable disease control, rural health including mother and child health, and education and training. Of the plan funds for health, about 40% is spent on health facilities and medical education. There is a strong urban bias in the pattern of health expenditure and the rate of utilisation of the rural health budget is low.

Figure 17. Health expenditure - Per capita, state-level

Source: Kakwani & Subbarao (1990b)

Currently in India there are over 3,000 hospitals with 95,000 beds in rural areas and 7,000 hospitals with over 500,000 beds in urban areas. In other words 70% of total hospital beds and-about 80% of the doctors are located in urban areas where only 25% of the population lives. In 1990, there were 20,531 primary health care centres (PHCs); one for every 41,000 rural population and 130,390 sub-centres, approximately one for every 6,500 population (Health Information of India 1990, published by the Ministry of Family Welfare, New Delhi). There is thus an evident imbalance in the health system, with too high a proportion of physicians practising in urban areas, inefficiently managed primary health care centres in rural areas undermining the confidence of people in using them and a general bias towards curative rather than preventive care.

Despite the number of PHCs and the fact that health manpower and services are increasing in absolute terms, it is still not keeping pace with population growth. There is a need to balance the meagre health resources, between rural and urban areas through a policy shift from urban to rural raising additional resources from public and private sectors, encouraging utilisation of existing services, and curbing their duplication.

Table 12: Per capita expenditure (Rs at current prices) on social services under successive Five-Year Plans (with % public sector outlay in brackets)

	1951-56	1956-61	1961-66	1969-74	1974-79	1980-85	1985-90
Public sector Plan outlay	52.1	112.7	185.1	185.1	152.6	1382.3	2303.8
Social	11.1	17.9	28.0	44.6	103.1	198.9	403.7
Services	(21.0)	(15.6)	(15.1)	(15.6)	(16.1)	(14.0)	(17.5)
Education	4.1 (7.5)	6.6 (5.5)	12.7 (6.9)	14.2 (5.0)	21.6 (3.3)	35.7 (2.6)	81.6 (3.5)
Health	2.6 (5.0)	5.2 (4.6)	4.8 (2.6)	6.1 (2.1)	12.3 (1.9)	25.8 (1.8)	43.4 (1.9)
Family Planning	-	0.05	0.5 (0.3)	5.0 (1.7)	7.9 (1.2)	14.3 (1.0)	41.6 (1-8)
Housing and Urban Services	0.9 (1.7)	1.9 (1.7)	2.7 (1.5)	4.4 (1.6)	18.6 (2.9)	35.2 (2.5)	54.1 (2.4)
Water Supply and Sanitation	-	-	2.3 (1.2)	8.5 (3.0)	17.6 (2.7)	55.6 (4.0)	83.4 (3.6)
Social Welfare and Related Fields	3.6 (6.7)	4.2 (3.7)	4.8 (2.5)	6.1 (2.1)	24.9 (3.9)	32.1 (2.3)	99.3 (5.0)

Note: Figures in brackets are percentages to total plan outlay

Source: Planning Commission

Immunization coverage

The Government of India launched a universal immunisation programme in 1985-88 which, according to the number of children immunized and the percentage of coverage to target (See Figure 18) appears to be running smoothly, although it often fails to provide the complete dosage (which is more important than simple coverage). The National Health Policy document sets the goal to cover 100% of pregnant women and infants with tetanus toxoid, and 85% of children for DPT, polio and BCG vaccines by 2000 AD.

Figure 18. Immunisation Coverage - % by 12m, % preg. women (tet)

Source: EPI, WHO.

Shelter, sanitation and water supply

Even though the number of dwelling units is increasing, the rate does not keep pace with the rate of population increase. The housing gap has increased steadily from 23 million in 1981 to 31 million dwelling units in 1991 and it will become worse by 2001 (UNICEF 1990). This widening gap though has been a middle-class concern, with the vast acute need of slum and pavement dwellers hardly entering the calculation (UNICEF 1990, p139). In rural areas, the shortage of shelter is both less visible and harder to assess.

Sanitation is linked closely to both shelter and water supply. According to government estimates (UNICEF 1990 p141), in 1981 only 25.1% of the urban population and 0.5% of the rural population had access to basic sanitary facilities. This coverage increased by 1985 to 28.4% and 0.7% respectively. The chances of reaching the reduced goals of the International Drinking Water Supply and Sanitation Decade of 50% urban and 5% rural coverage appear very remote indeed.

A study on water sources was carried out by NSSO during 1986-1987. The results showed that only 16% of rural and 72% urban population use a tap as a major source of drinking water. Efforts are being made to provide ‘drinking water’ to problem villages (i.e. villages where there is no source of drinking water within a distance of 1.6 km or within a depth of 15 metres). Other problem villages are those with excessive salinity, iron, fluoride etc. in water. As of April 1989, there were nearly 21,000 problem villages, which required drinking water (GOI 1989). The UNDP Human Development Report (1990) reports that the population with access to safe water in 1985-87 was 57%, compared to 31% in 1975.

Supply of drinking water is the primary responsibility of the State Government. The Accelerated Rural Water Supply Programme (ARWSP) is supported fully by the Central Government in order to provide safe drinking water to the population. By 2000 AD the Government sets its goal in the National Health Policy document to provide 100% population with a protected water supply.