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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 5  |  Page : 31-35  

Budgetary allocation for health sector projects in local bodies with specific reference to noncommunicable diseases control


1 Associate Professor, Department of Community Medicine, Government Medical College, Thiruvananthapuram; PhD Scholar, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Submission09-Aug-2022
Date of Acceptance17-Aug-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Srinivasan Kannan
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1071_22

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   Abstract 


Background: The role of local self-government (LSG) bodies in planning community-level interventions for noncommunicable diseases (NCD) control is critical. An understanding of how much priority is given to NCD in decentralized health planning is needed. Objective: The objective of this study is to analyze the pattern of budgetary allocation for health sector projects at different levels of LSGs in Thiruvananthapuram, Kerala, with specific reference to NCD control. Materials and Methods: Secondary data analysis was done on economic review reports and reports on health sector projects obtained from LSG department with permission. The pattern of budgetary allocation of health projects in both urban and rural local bodies of Thiruvananthapuram district for 2019–2020 was studied. Results: The proportion of NCD projects in terms of number and budget allocation, respectively, among health sector projects for gram panchayaths (GP) was 47 projects (5.25%) and 63.19 lakhs (1.8%). Figures for block panchayaths (BP) were 13 (9%) and 98.10 lakhs (10.94%), for district panchayath (DP), 1 (0.9%) and 48 lakhs (3%), for municipalities 1 (1.6%) and 4.66 lakhs (1.2%), and for corporation were 1 (1.4%) and 3 lakhs (0.16%). Only 29 (40%) GP and 5 (45%) BP had at least one NCD project. At the GP level, 21% of projects were community-based interventions and 15% of projects were for cancer screening, mental health, and hospital-based NCD clinics each. Among local bodies with lower allocation for NCD projects, the amount allocated for construction and maintenance work in health institutions was higher. Conclusion: Decision-making in decentralized health planning needs an evidence-based realignment of priorities toward NCD.

Keywords: Budget allocation, community interventions, decentralized planning, Kerala, noncommunicable diseases


How to cite this article:
Chintha S, Kannan S. Budgetary allocation for health sector projects in local bodies with specific reference to noncommunicable diseases control. Indian J Public Health 2022;66, Suppl S1:31-5

How to cite this URL:
Chintha S, Kannan S. Budgetary allocation for health sector projects in local bodies with specific reference to noncommunicable diseases control. Indian J Public Health [serial online] 2022 [cited 2022 Dec 4];66, Suppl S1:31-5. Available from: https://www.ijph.in/text.asp?2022/66/5/31/360642




   Introduction Top


Two-thirds of disease burden in India can be attributed to noncommunicable diseases (NCD).[1] The epidemiological transition level has been reported to be highest in the Indian state of Kerala.[2] Recent studies estimate that more than 80% of adults aged 18–64 years have at least one of the NCD risk factors. Raised Blood Pressure and raised Fasting blood glucose (FBG) are present in 30.4% and 19.2% of adults in Kerala.[3] Addressing the problem of NCD needs strategies targeting environmental and behavioral risk factors, and applying principles of primary health care.[4] Local self-government (LSG) bodies have a critical role in initiating and implementing community-level NCD control programs as well as supporting public health-care facilities in screening and treatment services.[5],[6],[7],[8],[9],[10] Although the share of morbidity and mortality due to NCDs outweigh all other diseases, the proportion of funds allocated by local governance bodies for NCD projects is reported to be inadequate.[9],[11] There is a need for local health system planners and managers to prioritize NCD care.[10],[12]

In 1994, the Kerala State Assembly passed the Panchayati Raj Act after the 73rd and 74th Constitutional Amendments, which has empowered local governance bodies with funds, functions, and functionaries. Kerala has successfully implemented decentralized planning through its LSG bodies. For decentralized planning, unique “projects” that were in the form of plans or schemes for accomplishing specific objectives were devised. Development projects covering all sectors are planned and implemented by the local bodies, of which health is an important area.[13] An understanding of how much priority is given to NCD in decentralized health planning and the type of interventions initiated will help us in planning effective strategies for NCD. This study aims to analyze the pattern of budgetary allocation for health sector projects at different levels of LSGs in Thiruvananthapuram with specific reference to NCD control.


   Materials and Methods Top


Secondary data analysis was done on digital datasets, available as reports on health sector projects from LSG department of Kerala. Thiruvananthapuram district, the state capital was selected for the study. The district with a population of 3.3 million, which has the second highest number of LSG bodies that comprised cities, towns, coastal, and hilly terrains including tribal areas.[14] All LSG bodies, both rural and urban at all three levels, namely, district, block, and gram panchayaths (GP) were included for the analysis. Data were analyzed for 2019–2020, the latest pre-COVID-19 planning period. For the present analysis, the criteria used for “NCD projects” included those projects that were aimed at prevention, screening, treatment, and rehabilitation for diabetes, hypertension, chronic lung, kidney, heart and liver diseases, cancers, substance abuse, and mental illness. It was mandatory for all LSGs to implement a palliative project; however, they were excluded from the present analysis for better comparison to study NCDs. Detailed analysis for understanding the pattern of budget allocation for different projects was performed on 30 randomly selected GP out of 73.

A data extraction form was developed based on the literature followed by expert consultations. We obtained data from LSG department, Government of Kerala with necessary permissions. Data cleaning and analysis were done using SPSS version 25.0 (SPSS IBM, Armonk, NY, USA). Variables studied were the type of health sector projects, amount and number of each project, LSG bodies with projects on NCD control, budget allocated for NCD, number of projects related to NCD, subsector analysis in terms of, allocation for modern medicine and AYUSH, category-wise analysis in terms of allocation for general, scheduled caste and special tribal population, allocation for HR, consumables, infrastructure, and community interventions. Analysis was done by calculating proportion of budget allocation based on actual amount allocated for each project, and number of projects for the abovementioned variables. The mean and standard deviation for the amount of allocation and number of projects across various types were estimated. The mean amount allocated for NCD projects was used as the cutoff for categorizing LSGs into high allocated LSG and low allocated LSG. The student's t-test was used for testing the significance of association between allocation in various projects and the amount allocated for NCD. P < 0.05 was considered statistically significant.


   Results Top


Data from all the 90 LSG bodies of Thiruvananthapuram district for which reports were available for 2019–2020 were analyzed for the present study. Data from all levels of local government from the district were analyzed, namely, one district panchayath (DP), one corporation, four municipalities, 11 BP, and 73 GP. The sector-wise analysis in terms of distribution of fund allocation at the LSG levels for productive, service, and infrastructure sectors, found that more than half (55%) of the allocation of funds from the LSG plan was on service sector in 2019–2020. Out of the allocation, only 6% was allocated for health-related projects (1284 projects). Out of those projects, 895 were at the village level (GP), 142 were at the block level (BP), 71 were at the city corporation, 112 were at the DP, and 60 were at four municipalities. The total budget allocated for the 1284 health projects was Rs. 8100 lakhs. At the village level, the GPs allocated Rs. 3433 lakhs (42.38%), and the BP allocated Rs. 897 lakhs (11.07%). The city corporation was a single entity that allocated the highest amount Rs. 1798 lakhs (22.19%), and that was followed by the DP with Rs 1584 lakhs (19.56%). The four municipalities together allocated Rs. 386 lakhs (4.76%). Corporation and DP allocated higher proportion of their total budget for health compared to other local bodies in terms of the percentage share of total allocation. The GPs allocated 47%, whereas BPs allocated 12.57%, DPs allocated 13.92%, municipalities with 14.44%, and the corporation body allocated 12.05%. In terms of distribution of fund allocation between allopathy and AYUSH, 49% on 629 projects were by allopathy, 18% on 232 projects by Ayurveda, 12% on 147 projects by homeopathy, and 3% on 42 projects by Siddha.

The LSGs of Thiruvananthapuram were implementing 63 NCD projects, which was 4.9% of the total number of health projects. The budget allocated for NCD through LSG projects in Thiruvananthapuram was Rs. 216.95 lakhs, which was 2.7% of the allocation for health projects. The mean allocation per NCD project was Rs. 3.4 lakhs. The proportion of NCD projects in terms of number and budget allocation, respectively, among health sector projects for GP were 47 projects (5.25%) and Rs. 63.19 lakhs (1.8%). The allocation at the BP level was 13 (9%) and Rs. 98.10 lakhs (10.94%), for DP level 1 (0.9%) and Rs. 48 lakhs (3%), at municipalities 1 (1.6%) and 4.66 lakhs (1.2%), and for corporation was 1 (1.4%) and 3 lakhs (0.16%). Less than half, that is 36 (40%) LSGs had at least one NCD project. Only 29 (40%) GP and 5 (45%) BP had at least one NCD project. [Table 1] shows the proportion of NCD projects in terms of number and budget allocated for health sector at all levels of local bodies.
Table 1: Proportion of noncommunicable disease projects in terms of number and budget allocation among health sector projects across local bodies

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The corporation of the district had only a single NCD project among 71 health projects, with an allocation of Rs 3 lakhs, implemented by homeopathic institution. The project was for improving the quality of life and prevention of relapses in stroke-affected patients. Out of the 112 health projects of DP, 82 (73%) were for construction and maintenance, 13 (12%) for establishment, 11 (10%) for purchases, 4 (3.6%) palliative projects, and 1 (0.9%) each for communicable and NCD. There was only one NCD project which was for establishing a dialysis unit at a Taluk hospital. The amount allocated for the project was 47.68 lakhs. In addition, another major health-related project at the district level was three water treatment plants, each worth 3 lakhs and a Tribal Sub-Plan project with the allocation of 5 lakhs rupees for conducting medical camps. Similarly, only one NCD project was implemented in one of the municipalities for the purchase of medicines, insulin, and other items essential for the treatment and management of NCD. The 11 BPs had 142 health projects, of which 13 were for NCD. Only one BP was performing well with eight NCD projects, one of which was a special component plan for the scheduled caste population. Among the NCD projects, 4 (31%) each were on two areas – mental health and community-based NCD program. Three (23%) projects were for cancer screening, one each for special diabetes clinic and health education. At the GP level, 21% of projects were community-based interventions and 15% of projects were for cancer screening, mental health, and hospital-based NCD clinics each. Two GP had projects for fitness center establishment. Of the total 61 NCD projects across three levels of panchayaths, 13 (21%) projects each were on NCD clinics and NCD screening. Mental health was addressed in 11 (18%) projects and 10 (16%) for cancer screening. Special clinics were planned through 5 (8%) projects. There were no projects specifically focusing on dietary modifications for NCD control. [Table 2] shows the type of NCD projects implemented across three levels of panchayaths in Thiruvananthapuram district.
Table 2: Type of noncommunicable disease projects implemented at three levels of panchayaths

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A detailed analysis of pattern of budget allocation across various types of LSG projects was done among 30 randomly selected GP of Thiruvananthapuram district. The mean (SD) of allocation and its range is given in [Table 3]. The highest allocation was for the purchase of medicines, with 30.3% (468 lakhs), followed by construction and maintenance, 28.2% (436 lakhs). Those projects on the purchase of medicines for NCD clinics were included in the NCD category. Another major category was palliative care with an allocation of 21.3% (330 lakhs). Allocation for NCD projects excluding palliative care accounted only for 5.2% (81 lakhs). The total allocation for NCD projects including palliative care was 26.5% (411 lakhs). The GPs were classified into two categories, namely, high and low for NCD projects fund allocation as mentioned above. This was based on the average fund allocated. The association of pattern of allocation in different projects with the amount allocated to NCD projects was studied and is shown in [Table 4]. Out of the 30 GPs studied, 19 (63.3%) had an allocation of <2.7 lakhs for NCD projects. Moreover, the number of GPs with no NCD projects was 11 (36.7%). GPs with more than the average allocation for NCD projects had significantly higher allocation for community-level interventions and mental health. Allocation for palliative care and purchases were also higher for those GPs. Among local bodies with lower allocation for NCD projects, the amount allocated for construction and maintenance work in health institutions was higher. The allocation for NCD increased with increase in total allocation for health.
Table 3: Pattern of budget allocation across various local self-government projects (n=30 Gram panchayaths

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Table 4: Association of allocation for noncommunicable disease projects and other projects (n=30 Gram panchayaths)

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   Discussion Top


This study brings out the pattern of allocation for health sector projects across different levels of LSG in Thiruvananthapuram district with specific reference to NCD. The allocation for health projects itself is meager (3.3%) similar to the pattern observed nationally as well as in the state. As per national level estimates, the percentage of health expenditure spent on preventive care is 6%. The percentage share of local bodies as a financing source in health expenditure is 1%.[4] The share of NCD expenditure in the National Health Mission is <5% and for NPCDCS is <2%. When it comes to local levels, financial and managerial resource allocations for NCDs become all the more suboptimal. Compared to the global and national focus on care for NCDs, prioritization in local health systems is reported to be low.[12] Among the 1284 health projects, only 63 (4.9%) of projects are specifically for NCD. Out of Rs. 8098 lakhs allocated for health projects, only 217 lakhs, that is 2.7% of allocation are for NCD Projects. More than 70% of projects were for construction and maintenance. Even among NCD projects, priority is given to NCD Clinics. BP and GP in Thiruvananthapuram had projects on NCD screening, cancer screening, and mental health. Still, the proportion of budget allocated is dismally low when compared with the morbidity and mortality contributed by NCD. The focus is mostly on infrastructure, purchase of medicines, conduct of medical camps, and health education sessions.[9],[11] It is widely acknowledged that local governments can play a vital role in enhancing the quality of the health-care delivery system and thereby the health status of the local community.

There are community-based interventions at GP and some exemplary projects at the block level. However, such projects constitute only around 20% of NCD projects. Projects other than screening camps and health awareness programs are relatively less. Only two projects were specifically focused on physical activity and none were there on diet. Innovative projects for primary prevention of NCD by community-level interventions in improving healthy living are implemented by certain local bodies but are significantly less.[15] There is wide acceptance among all levels of stakeholders that the problem of NCD can be controlled by strategies focusing on prevention and applying principles of Primary Health Care. Prevention of NCD requires sustainable community-level interventions.[4] Moreover, individuals can be held responsible only when structural opportunities for making choices exist. Hence, the provision of optimal architecture for healthy choices (”nudges”) including proper spaces for physical activity, sufficient resources, information for following a healthy diet, etc., are needed.[16] The limitation of our study was that we could not include the amount allocated to NCD through nonspecific projects on construction and purchases.

While analyzing association between pattern of allocation for various types of projects and allocation for NCD, certain interesting patterns are emerging. Further studies are needed to explore such associations as well as other determinants for decision-making in NCD allocation. Decentralized planning and priority setting need a change in focus toward NCD control. Most of the time, fixing of priorities while planning is not purely based on a rational-/evidence-based need assessment. To what extent NCD policies and strategies align with a decentralized health system needs to be studied further.

Acknowledgment

We thank the officials of LSG Department, Kerala, for giving us the data and permissions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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