Nine of India’s poorest states – home to 581 million or 48 percent of India’s population – account for 70 percent of the country’s infant deaths, 75 percent of under-five deaths and 62 percent of maternal deaths, but do not spend even the money they have set aside for healthcare, according to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets.

The data also reveals:

38 percent and 40 percent children in these states are underweight (low weight-for-age) and stunted (low height-for-age), respectively, higher than the national average of 36 percent and 38 percent, respectively, according to 2015-16 national health data, the latest available.

The nine poorest large states – in official jargon called “high-focus”, a term that implies they need special attention – spent an average of 4.7 percent of their social-sector expenditure on public healthcare and family welfare annually, marginally less than the national average of 4.8 percent.

Social-sector expenditure includes water supply and sanitation, housing and urban development.

India’s average spending on health, as a proportion of gross domestic product, is already the lowest among BRICS nations, as IndiaSpend reported on 8 May 2017.

"In 2005, it was observed by (the) government of India that some states were performing poorly in various indicators. So, these states were clubbed together as high-focus states and additional resources were given to improve those indicators,” Avani Kapur, Senior Researcher, Accountability Initiative, said.

Poorest States Spent Less Money Than Their Budgets Allowed

Of the nine poorest states, Rajasthan spent the highest (5.6 percent) and Bihar the lowest (3.8 percent) proportion of aggregate expenditure on public healthcare and family welfare, according to the RBI data on 2014-15 actual spending, lower than the budgeted 4.1 percent for Bihar and 6.6 percent for Rajasthan.

Seven of the nine “high-focus” states report such underspending. Avani Kapur, Senior Researcher, Accountability Initiative, said:

So, while some “high-focus” states spent less money than set aside by their budgets, other states outspent – by proportion as ratio to aggregate expenditure – other larger states on healthcare and family welfare, but that had no relation to their healthcare indicators.

In contrast, Andhra Pradesh (84.6 million people), another big state, spent 4.1 percent of total expenditure on public healthcare and family welfare but reported an MMR of 92, according to government data.

Since 2008, Rajasthan increased its spending by 0.8 percent and its MMR decreased 23 percent while Andhra Pradesh’s spending increased by 0.5 percent and MMR decreased 31 percent.

Madhya Pradesh, which reported an infant mortality rate (IMR) – deaths per 1,000 live births – of 51 in 2015-16, spends 4.3 percent of total expenditure on healthcare–against 5 percent that was budgeted – and, as IndiaSpend reported on 21 January 2016, is worse off than some of the world’s poorest countries, such as the Gambia and Ethiopia.

Spending More on Healthcare did not Improve Institutional Births

In the nine “high-focus” states we studied, 72.6 percent of all births were in healthcare institutions, a steady improvement but below the national average of 78.9 percent, according to the 2015-16 National Family Health Survey (NFHS-4) data, the latest available.

Uttar Pradesh (78), Madhya Pradesh (65), Chhattisgarh (64), Bihar (58) and Assam (56) report India’s highest under-five mortality rates – deaths per 1,000 live births –IndiaSpend reported on 20 March 2017.

Odisha reported an 118 percent increase in institutional births over 10 years, but the IMR declined by no more than 63 percent over this period.

Not Enough Doctors and Healthcare institutions

Bihar is 81 percent short of community health centres (CHCs), which provide secondary healthcare in the form of referrals and specialists to rural areas, and Jharkhand is 66 percent short of primary healthcare centres (PHCs), the first point of access to a qualified public-sector doctor in rural areas, according to the RBI report.

There is a 13 percent shortfall of CHCs in the “high-focus” states, according to India’s Health Management Information System.

Bihar was 93 percent short of specialists in CHCs, while the comparable figures were 90 percent, 84 percent and 84 percent in Chhattisgarh, Uttar Pradesh and Jharkhand, respectively, in March 2016, according to Accountability Initiative budget brief on National Health Mission.

Such infrastructure shortages exacerbate inadequate spending and deliver low heath achievements. Increased primary healthcare spending reduces child and infant mortality rates, according to this 1999 research paper by the International Monetary Fund.

Promoting community-based education on improved maternal and newborn care, and home-based treatment for newborn infections could enhance child survival in the “high- focus” states “significantly”, said the 2012 PLOS-ONE study.

(This story was published in an arrangement with India Spend.)