Title

National Disease Control Program Expenditures

Creator

Ravi Duggal

Sunil Nandraj

Date

1998

extracted text

/S7

National Disease Control Program Expenditures

Ravi Duggal and Sunil Nandraj

Selected diseases have at different points of time received special attention
and separate allocation of resources. In the past small pox was one such
disease which had a separate budget and staff to tackle the problem on a war
footing. In the past many such programs were of a vertical nature having
their own budgets and staff. Malaria and leprosy programs, apart from small
pox were the main vertical programs. While the war against small pox was
successful, that against malaria reached a certain success in the mid-sixties
but after chat malaria has come back with a vengeance and continues to be a
major program (but without its vertical structure) . Leprosy continues to be a
vertical program and in recent years has shown good results. The tuberculosis
and the blindness control programs have had no such luck and have always
received a step-motherly treatment under public health care.

Disease Programs on an average during this decade have received 10% of the
State's health care budget and the trend is a declining one. In percapita
terms at the national level today a measly amount of Rs.8 per person is being
spent on these programs. If one looks at the disease profile of the country
then this expenditure itself is very low to fight these diseases. (Ofcourse,
it must be noted that three-fourth of health care is sought in the private
sector hence the actual percapita value would be four times.) The decline in
expenditure on these programs is mainly in Assam, Bihar, Himachal, Karnataka,
MP, Orissa, Punjab, Rajasthan, and Tamil Nadu.
If we break down the expenditure by various diseases we find that between 80%
and 95% is spent on just four programs malaria, leprosy, tuberculosis and
blindness. Further, of the total disease program expenditure 50% to 60% is
spent on the malaria program alone, followed by about 20% on leprosy.
Tuberculosis and blindness control gets under five percent.

Malaria
The prevalence of malaria is very high right across the length and breadth of
the country; with only Kerala and Goa being exceptions. The NFHS study in
1992-^3 gives a 3 month incidence rate of 3324 per 100,000 population, which
means about 105 million new cases every year. The rural areas recorded an
incidence of nearly twice that of urban areas. While most states show a
fairly high share of expenditure for the malaria program from the total
disease program budget, it must be noted that most of it goes to salaries of
staff who may not be doing any work related to malaria. For historical
reasons most multipurpose workers (MPWs) get their salary from the malaria
Department because they were erstwhile malaria workers and today are MPWs who
may be doing very little malaria related work. Hence, what actually is spent
to treat or control malaria may be a very small amount of the national
malaria budget of about Rs.5000 million which initself may be quite adequate
to fight malaria under a comprehensive
health program.

Leprosy
According to the 1981 cer.sus India had 4.2 million active leprosy cases. The
NFHS survey a decade later in 1992-93 recorded a prevalence rate four times
less than the 1981 census making for a caseload of 1.2 million cases. While
ft

I P*

7

1

one may argue that the NFHS may have made an undercount' there is no doubt
r.h-ii i.he leprosy program has had a major impact, and this perhaps due to
three reasons - reasonably sufficient allocation of funds, better management
of the program albe-it through a vertical structure, and treatment largely
being availed in the public sector.
Tuberculosis

The tuberculosis control program is perhaps the worst performer and the main
reason is very poor allocation of funds in the public system. Further, since
tuberculosis begins symptomatically with cough and fever it is treated mainly
in the private sector which exploits patients with irrational therapy
comprising of cough syrups, tonics and broad spectrum antibiotics. Today
there are about 14 million estimated active cases of TB in the country and
the state pays very little attention to it. An evaluation team of GOI-WHOSIDA found that the drugs available in the public system were sufficient to
treat only one-third of the patients who actually were receiving care within
the public system - this means that the average patient would get only onethird of the treatment required and hence would return with a relapse
Blindness
With 9 million blind persons and 45 million with severe visual impairment
this is a very serious scenario, The present focus is on cataract surgery and
vitamin A deficiency. The care of the completely blind is under the social
welfare department. The resources available for handling cataract and vitamin
A deficiency cases is very meager and needs to be enhanced substantially.

The Salary Syndrome
Of the budgets allocated for various programs salaries take away 70% to 90%
of the resources leaving very little behind for other inputs like drugs,
equipments, travel etc... While one recognizes that the health sector is
clearly a labour intensive one where human resource is the most valuable
input, it cannot be denied.that without adequate drugs, diagnostics etc. the
human resource has little value. Thus if in the present situation 80% of the
resource, and increasingly so, goes for paying salaries then the health
workforce cannot be effective with the meager resources left over to treat
patients, and for preventive and promotive care. If for instance we look at
the teaching hospital or other large city hospitals we find that salaries
account for about 40% of the budget and thus these hospitals perform more
effectively than their rural counterparts like rural hospitals and primary
health centres.-It must be emphasized here that percentages have been used in
the data only as a proxy tool. A more realistic analysis would include using
morbidity data to determine the financial requirements or costs needed to
deal with it. Unfortunately at the present moment such data is difficult to
come' by, though we have made a brief attempt in Table 4, but its limitations
are explained in the table itself.

The data in the tables below have been extracted from the CEilAT database
which was put together for the national research program on Strategies and
Financing for Human Development and this is available presently as a
monograph titled Financing of Disease Control Programmes in India by the
present authors.

TABLE 1 : EXPENDITURE ON SELECTED DISEASE PROGRAMS

(.id p«raoni'.igo;i ro Tdi.i1 llo.ilrh)
Year

Malaria

Andhra Pradesh
1990 - 1991
10.11
1994 - 1995
9.82
Assam
1990 - 1991
7.36
1994 - 1995
3.90
Bihar
1992 - 1993
4.96
1994 - 1995
5.41
Gujarat
1990 - 1991
4.59
1994 - 1995
7.12
Haryana
1990 - 1991
10.72
1994 - 1995
11.57
Karnataka
1990 - 1991
3.40
1994 - 1995
3.27
Kerala
1990 - 1991
1.43
1994 - 1995
1.75
Madhya Pradesh
1990 - 1991
7 . 18
1994 - 1995
7.12
Maharashtra
1990 - 1991
8.58
1994 - 1995
6.60
Orissa
1990 - 1991
5.36
1991 - 1992
5.73
Punjab
1990 - 1991
8.43
1994 - 1995
5.67
Rajasthan
1990
1991
6.66
1994
1995
5.74
Tamil Nadu
1992
1993
1994
1995
Uttar Pradesh
1990
1991
7.84
1994
7.11
1995
West Bengal
1990 - 1991
6.89
1994 - 1995
4.27
Arunachal Pradesh
1990 - 1991
:
;2.60
1994 - 1995
:
4.57
Gca
1990 - :1991
. 99
1994 - 1995
'
.77
Mizoram
4.07
1990 - :1991
1994 - :1995
3.92
Himachal Pradesh
1990
1991
4.84
1995
4 . 17
1994
t.

TB

Leprosy Blindness

AIDS

All Diseases

Total Health
(Rs millions)

1.25
1.42

4.62
4.97

.21
.28

.00
' .48

16.11
18.79

3325.10
5043.53

1.42
. 97

1.48
1.32

.75
. 80

.00
.00

17.29
7.26

941.22
1883.92

. 27
. 19

3.39
2.89

.12
.08

.00
.00

9.18
10.34

3856.38
5574.54

2.48
2.95

1.78
1.60

.84
.78

.00
.41

10.89
13.76

2478.16
3593.73

1.81
4.36

. 08
.05

.24
.75

.00
.50

12.30
15.33

917.60
1396.29

1.80
1.90

.84
. 95

.29
. 47

.00
. 69

4.70
5.58

2698.20
5077.72

.80
1.01

. 99
1.53

.20
.45

.00
.05

3.96
5.98

2224.32
3759.77

.37
2.31

2.36
1.86

.70
.86

.00
.60

11.02
8.84

2647.20
4609.97

2.80
2.48

3.00
2.85

. 10
.07

.07
.41

14.34
11.87

4341.15
6803.92

1.46
1.67

3.66
4.33

. 17
.27

.00
.00

11.29
10.98

1550.21
1565.99

1.72
2.31

.14
. 19

. 18
.38

.00
.48

11.88
6.90

1765.76
2312.75

2.56
2.23

.40
.36

.26
.44

.00
. 14

8.65
8.18

2555.20
4556.96

1.38
1.57

3.54
3.63

.28
.26

.04
.02

4.83
6.20

4894.22
5982.37

3.07
2.16

2.45
1.93

.51
.34

.00
.14

15.85
17.35

5826.32
8003.05

3.74
3.07

2.43
1.63

. 23
.23

.00
. 15

13.20
9.18

3256.13
5397.64

2.24
2.40

.86
. 68

.33
.21

.00
.00

19.14
11.73

144.86
278.07

2.77
2.31

1.70
1.43

.36
.33

.00
.29

5.51
5.13

232.15
350.86

2.56
2.84

2.01
1.69

.57
.83

.00
.05

11.83

152.10
198.63

.96
. 96

1.37
1.22

.57
.47

.00
.72

10.12
11.24

651.42
1274.81

T

Table 1

.nl.

Manipur
1989' - 1 -90
1991 - 1 '92

4.81
2.72

2.25
2.29

3.37
3.03

.74
.73

.00
.00

18.38

165.10
216.53

Megnalay.
1990
1'91
1994
1 -95

8.71
6.00

.25
. 36

2.03
2.00

.59
1.02

.00
. .59

15.02
4.04

212.45
367.38

7.63
6.52

3.95
3.56

2.64
2.38

1.27
. 36

.00
3.24

16.16
16.62

203.80
310.82

4.90
3.16

1.12
.41

1.12
1.44

.57
. 69

.00
.00

9.80
8.66

70.80
145.80

11.24
4.86

. 65
.81

2.56
2.31

.91
1.77

.00
1.53

15.47
9.42

259.86
368.26

Nagalanc
1991 - . . 92
1994 - ' 1 is
Sikkim
1990 - 1 -91
1994 - : ?5
Tripura
1990 - 1 -91
1994 - 1 - = 5

Notes
:* Data breakup not available; 1994-95 data are budget estimates
Sources : Respective State government. Demand for Grants, 1993 - 94 and 1994

TABLE 2

YEAR

r.

: EXPENDITURE ON SALARIES FOR DISEASE PROGRAMS

MALARIA
as % Actuals

Andhra Pradesh
80.00
1990 - 1991
93.29
1994 - 1995
Assam
.00
1990 - 1991
9.55
1994 - 1995
Bihar
95.25
1992 - : >93
86.88
1994 - . 995
Gujarat
5.90
1990 •91
1994 - . -95
3.80
Haryana
81.14
1990 - 991
77.95
1994
. '95
Karnata ■. a
.00
1990 - 991
24.06
1994 - .995
Kerala
92.05
1990
1991
90.80
1994
1995
Madhya Pradesh
’ 991
7 9.81
1990
66.18
1995
1994
Maharashtra
68.25
1990 - 1991
76.40
1994 - 1995
Orissa
82.74
1990 - 1991
34.05
1991 - 1992
Punjab
68.28
1990 - 1991
83.45
1994 - 1995

95.

LEPROSY
Actuals

BLINDNESS
as %
Actuals

TUBERCULUSOIS
as %
Actuals

as %

336.46
495.42

82.53
81.91

41.85
71.58

85.22
88.88

153.69
250.64

10.21
8.43

7.05
14.36

69.32
73.51

16.60
56.59

13.43
18.20

.00
56.64

14.02
24.91

.00
.00

7.10
15.06

191.25
301.39

2.90
3.24

10.34
10.49

99.54
104.70

130.74
161.19

38.66
34.34

4.63
4.63

113.95
256.03

57.38
41.70

61.47
105.85

68.54
67.63

44.22
57.67

62.75
7 9.57

21.02
28.10

98.41
161.51

60.75
39.60

16.61
60.83

58.11
77.27

.74
.66

11.76
.00

2.21
10.54

91.97
166.27

66.92
48.26

48.82
96.65

35.60
10.50

22.67
48.48

.00
.00

•7.85
23.80

31.95
65.86

51.96
53.59

17.90
37.90

97.69
96.67

22.04
57'. 37

89.24
70.80

4.46
16.92

190.22
328.04

35.36
73.61

10.04
106.56

83.83
86.50

62.72
85.95

66.29
61.13

18.66
39.46

372.50
448.81

49.66
48.48

121.84
168.50

80.87
78.59

130.39
194.07

.00
.00

4.43
5.04

83.14
89.68

69.37
72.72

22.72
26.21

85.53
86.88

56.88
67.75

92.83
32.70

2.79
4.22

148.98
131.15

79.32
65.38

30.41
53.50

91.13
87.05

2.48
4 . 48

52.94
55.77

3.23
8.75

2

Table 2 Cont.

Rajasthan
1990 - 1991
71.46 1994 - 1995
71.41
Tamil Nadu
1992
1993
1994
1995
Uttar Pradesh
1990
1991
72.48
1994
1995
75.09
West Bengal
1989
1990
96.31
1994
94.72
1995
Arunachal Pradesh
1990 - 1991
:
93.39
1994 - 1995
:
78.52
Goa
1990 - :1991
78.88
1994 - :1995
85.93
Mizoram
95.00
1990 - 1991
:
99.36
1994 - :1995
Himachal Pradesh
83.96
1990 - 1991
82.95
1994 - 1995
Manipur
1991’ - 1992
.00
Meghalaya
1991
.00
1990
86.11
1994
1995
Nagaland
74.98
1990 - 1991
1994 - 1995
88.70
Sikkim
1990 - 1991
91.35
1994 - 1995
96.30
Tripura
1990 - 1991
56.33
1994 - 1995
45.17

170.37
261.60

67.49
62.84

65.61
101.57

88.96
92.04

10.24
16.59

33.53
17.98

6.77
19.85

.00
.00

55.52
52.20

67.53
94.00

92.93
93.32

173.10
217.01

78.92
85.02

13.66
15.75

457.20
569.33

86.11
59.15

179.33
172.87

77.41
80.34

143.09
154.19

62.14
50.92

30.16
27.20

147.75
230.59

77.01
72.52

96.05
165.56

87.97
91.81

63.36
87.87

92.53
81.29

4.82
12.56

3.78
12.71

88.62
68.97

3.25
6.67

92.80
89.95

1.25
1.89

.00
.00

.49
.59

2.32
2.70

82.61
86.42

6.44
8.10

82.78
87.20

3.95
5.00

92.86
93.10

.84
1.16

6.20
7.78

88.46
93.27

3.90
5.65

90.20
97.61

3.06
3.35

90.80
95.76

.87
1.65

31.54
53.20

32.59
35,46

6.29
12.21

86.58
83.89

8.94
15.52

.00
.00

3.77
5.94

5.89

. 00

4.96

.00

6.56

.00

1.57

18.61
22.03

.00
66.41

.54
1.31

.00
148.03

4.'34
7.35

.00
72.73

1.27
3.74

16.27
20.27

75.36
82.17

7.71
11.05

114.73
123.00

5.16
7.39

.00
.00

.61
1.11

3.47
4.60

62.50
71.67

.80
. 60

.00
.00

.80
2.10

.00
.00

.41
1.00

29.22
17.91

23.67
19.46

1.69
2.98

77.66
76.35

6.67
8.50

45.15
46.92

2.37
6.50

Notes
* Data not avaiable; Actuals are in Rs millions spent on each disease program.
Sources : Respective state government, Demand for Grants, 1993 - 94 and 1994 - 95.

4

!

TABLE
STATE

i

PREVALENCE or SELECTED DISEASES 1992
(per 100,000 population)
MALA'RIA

ANDHRA PRADESH
7776
ASSAM
10828
BIHAR
5712
GUJARAT
12912
HARYANA
3732
JAMMU & KASHMIR*
3412
KARNATAKA
1828
KERALA
448
MADHYA PRADESH
18912
MAHARASHTRA
14968
ORISSA
20592
PUNJAB
10184
RAJASTHAN
20412
2304
TAMIL NADU
UTTAR PRADESH
29580
WEST BENGAL
2712
ARUNACHAL PRADESH 16852
972
GOA
MIZORAM
18544
HIMMACHAL PRADESH 4564
6564
MANIPUR
MEGHALAYA
22892
11112
NAGALAND
NA
SIKKIM
10476
TRIPURA
INDIA
13296

1993

TUBERCULOSIS

LEPROSY

BLINDNESS

407
638
595
308
327
245
136
586
435
293
555
238
724
703
560
357
938
179
311
242
941
321
491
NA
289
4 67

118
36
123
29
14
18
132
18
136
72
96
28
128
209
222
47
110
16
33
56
199
17
153
NA
0
120

5984
1106
274 9
3266
824
869
4900
1404
3831
3534
3161
863
4661
836
3101
914
1012
2714
1524
1384
1442
759
1373
NA
1430
3001

1) * = Refers only to Jammu region.
2) Malaria data is incidence of cases. The NFHS data was for 3 months, we
multiplied it by 4 to arrive at the annual figure. For other diseases it
is point prevalence.
National Family Health Survey 1992-93 : All India,International Institute
Source :
for Populatibn Sciences, Bombay, August 1995 (Pg. 205, Tables 8.2)

Notes :

V

xvo

x vjXju

x/Vv/vAaSjCux,

(in rupees)
The per case expenditure is a normative figure because it is well
known that
a)
i
actual utilisation of these government
programs is only by one fourth to one third
of the population and b)
the establishment costs (salaries etc.)
takes away about
Chios fourth of this expenditure. Therefore, the real expenditure per actual case is
much higher, but this data helps us look at allocations in terms of disease prevalence
across diseases.

MALARIA

STATE

ANDHRA PRADESH
77
ASSAM
29
BIHAR
37
GUJARAT
29
HARYANA
210
JAMMU & KASHMIR * NA
157
KARNATAKA
274
KERALA
14
MADHYA PRADESH
MAHARASHTRA
33
13
ORISSA
76
PUNJAB
22
RAJASTHAN
NA
TAMIL NADU
UTTAR PRADESH
15
109
WEST BENGAL
ARUNACHAL PRADESH 43
212
GOA
52
MIZORAM
HIMMACHAL PRADESH 186
46
MANIPUR
MEGHALAYA
42
NAGALAND
116
NA
SIKKIM
33
TRIPURA
NA
INDIA
Notes :

Sourc^j. :

TUBERCULOSIS

LEPROSY

BLINDNESS

186
52
19
587
567
NA
1001
96
214
529
146
567
207
167
158
448
658
3426
1985
593
270
733
1386
NA
124
NA

2445
2448
1175
4693
189
NA
427
5875
811
3002
2185
390
281
1438
891
2484
2431
24070
12444
3628
1690
19265
2919
NA
NA
NA

3
24
2
18
43
NA
5
12
9
2
4
22
6
28
8
25
280
47
136
49
56
139
68
NA
59
NA

Refers only to Jammu region.
2) The expenditure figures for Orissa and Manipur refer to year 1991-92
Prevalence data : National Family Health Survey 1992-93 : All India,
International Institute for Population Sciences, Bombay, August 1995
(Pg. 205, Tables 8.2)
Expend.ute data : Respective state government Demand for Grants,
1994 - 95

1)

T