More money is not always the answer to the ills of global health

By Laura Downey Jul. 25, 2017

Increasing the amount of money spent on health isn’t always the answer, especially in the absence of a system that can readily and effectively absorb additional funds. Laura Downey discusses this in the context of India in the following blog.

According to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets, nine of India’s poorest states (48% of the population) account for 75% of under-five deaths and 62% of maternal deaths. The Central Government recognised these nine states as ‘high-focus’ as they were performing poorly in various indicators and allocated additional resources to them to improve health indicators. However, these ‘high-focus’ states spent less money than was allocated to them and indicators did not improve.

A growing number of LMIC are transitioning from development assistance in health towards increased domestic expenditure. An important determinant of success or failure will be the strength of system-wide mechanisms to engage in effective priority setting of resources and govern their deployment. India is not alone in the problem of absorbing finances allocated for health, a recent WHO report similarly described an underspend of 20-40% of money allocated to heath in Sub Saharan African countries. We know from global surveillance data that health expenditure is rising in most countries across the world, yet startling figures recently released by the OECD reveal that a considerable proportion of this expenditure has little to no impact on improving people’s health. This is consistent with a 2010 WHO analysis which concluded that 20-40% of healthcare spending globally is wasted.

Improving the ability of ‘high focus’ states in India to adequately absorb allocated funds will require robust mechanisms, to both engage in effective priority setting and ensure system readiness for implementation.

The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, will be critical in strengthening the Indian healthcare system.

The government of India is set to establish a Medical Technology Assessment Board (MTAB). The MTAB will evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system, and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process for healthcare decision making in India, towards the ultimate goal of achieving UHC. This formidable task will be crucial if States are to be empowered to adequately absorb and spend all funds allocated to them by the Central government to maximise health gains.

However, engaging in effective priory setting is only half the battle. Effective uptake of resource allocation decisions requires a system able to deliver and strong governance mechanisms to ensure that policies are properly implemented. Since moving into upper middle income status, the Indian government has made valiant efforts to strengthen the highly complex and fragmented health system. This is best evidenced through programs such as Rashtriya Swasthya Bima Yoganda (RSBY): the world’s largest social insurance program for those below the poverty line, which provides around 1000 secondary care services to registered card holders free at the point of delivery. However, the efficacy of such a program is severely impeded within the context of scant governance and regulation. Within months of the introduction of RSBY, stories began to emerge of profiteering clinicians cashing in on the capitation payment system by performing hysterectomies on whole villages of women. A largely unregulated and private-dominated care system means there is limited clinical surveillance data to ensure appropriate care provision and validate rebate charges. Without robust governance mechanisms, the value of effective priority setting is severely diminished. The importance of supply-side insufficiencies should also not be overlooked. Ensuring an adequate number of well-trained and reasonably paid health professionals with access to necessary equipment and infrastructure is critical to ensure a fit for purpose delivery system.

More money does not mean more health when the right systems are not in place to spend that money wisely, effectively implement policy decisions, and govern their deployment. It is the duty of the global health community to rise to the challenge to support policymakers across the world. Helping them to spend their money better to fully absorb available resources will maximise the value of every rupee or dollar spent, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.