FormalPara Key Points for Decision Makers

We observed a trend for increasing use of the budget allocated for National Rural Health Mission (NRHM) maternal and child health (MCH) strategies and significant improvements in MCH indicators.

These findings provide important insights into how the state used national funds to implement the NRHM to improve MCH.

These findings could have implications for the implementation and evaluation of national programmes in low- and middle-income countries.

1 Introduction

In India, from 1990 to 2015, the maternal mortality ratio (MMR) declined from 554 to 174 per 100,000 live births [1], and the infant mortality rate (IMR) declined from 165 to 38 per 1000 live births [2]. However, the millennium development goals for India included reducing the MMR to <100 per 100,000 live births and the IMR to 30 per 1000 live births, which were not achieved by 2015 [3]. Reasons for this slow reduction in maternal and infant mortality included the high proportion of home deliveries (up to 70%), the inadequate number of skilled birth attendants, poor-quality services in health facilities (lack of equipment, blood storage units or drugs and poor logistics [4]), lack of community involvement in the planning and monitoring of the national programme [5, 6] and lack of sufficient state health funding in the public healthcare delivery system. Accordingly, a multi-strategy community intervention, the National Rural Health Mission (NRHM), was implemented in India from 2005 to 2012; after 2012, it continued as the National Health Mission.

The aim of the NRHM was to improve the availability of and access to better-quality healthcare, especially for low-income mothers and children by implementing four major health sector plans: health system strengthening, communitization, and specific maternal and child healthcare strategies [7, 8]. Strengthening of the health system included improving infrastructure and increasing human resources, drugs and logistics, mobile medical units and patient transport services. Communitization included appointing accredited social health activists within villages, creating village health nutrition and sanitation committees, celebrating village health and nutrition days, and creating Patient Welfare Committees (Rogi Kalyan Samities) in health facilities. Maternal and child health (MCH) schemes included offering financial incentives for pregnant women to deliver in hospital (Mother Security Scheme [Janani Suraksha Yojana]), free delivery services and medical treatment for infants (Janani Shishu Suraksha Karyakaram), integrated management of neonatal and childhood illnesses, facility-based and home-based newborn care, and nutritional rehabilitation centres. These MCH plans were adopted on the basis of their proven effectiveness in reducing maternal and child mortality [8,9,10,11,12].

Several evaluations of the NRHM [13, 14] and its MCH strategies [15,16,17] and of national demographic surveys have shown that the use of MCH services in the public sector increased [18] and that MCH inequalities decreased [19] during the NRHM implementation period [18]. On the other hand, geographical and socioeconomic inequalities and inefficiencies in infrastructure and human resources remained. None of the evaluations conducted thus far have investigated what proportion of the budget dedicated to implementing MCH strategies under NRHM was actually used by individual states. Such budgetary information is important for efficient use of resources and effective implementation of strategies, especially in resource-constrained low- and middle-income countries. Similar investigations relating to MCH have also been carried out in Tanzania and the USA [20, 21]. The objective of this study was to examine trends relating to the intergovernmental (use of central government funds by state governments) budgets allocated to NRHM from 2005–2006 to 2012–2013 in Haryana, North India. This indirectly quantifies the extent to which these plans were implemented in each state.

2 Methods

Ethical approval for this study was provided by the author's institute in India.

2.1 Study Design and Area

We undertook a retrospective assessment of the budgetary outlay of NRHM MCH plans in Haryana, a state in North India that is assumed to be representative of other North Indian states. An outline of the healthcare delivery system within the state can be found in the protocol study [22]. We estimated the extent of implementation by comparing the budget allocated versus the budget utilized. Health financing is a basic building block of a health system and affects the availability of a sufficiently large health workforce and of essential medicines, impacting service delivery and ultimately mortality statistics [23].

2.2 Budgeting Process for Implementing Maternal and Child Health (MCH) Sector Plans Under the National Rural Health Mission (NRHM)

To implement the NRHM strategies, institutional arrangement and financial management groups were created at national, state and district levels [24, 25]. Each state prepared an annual programme implementation plan for the NRHM health sector plans, including the budgetary requirements for the following financial year [26, 27]. These programmes comprised five major parts: Part A included reproductive, maternal, child and adolescent health strategies, human resources, programme management, institutional strengthening and training; part B included communitization, new constructions, medical mobile units, referral transport and procurement, among others; part C related to immunization; part D to other national disease control programmes; and part E to funds required for convergence with other sectors. This study is restricted to parts A, B and C, which cover all the MCH strategies under the NRHM. Once district action plans were created, they were sent to the state, which then compiled all district health action plans and prepared the final state programme implementation plan. This was then sent to the central government for funding approval; once this approval was granted, funds were released to the states.

Initially, full funding was provided by the central government to implement the NRHM health sector plans within the individual states [28]. Gradually, the states had to contribute up to 25% of the state health budget to increase total expenditure on health from 0.9 to 3% of the gross domestic product. The NRHM provided flexible financing of the health sector plans/schemes so states could prioritize the expenditure based upon their needs; unspent funds under one scheme could be reallocated to another scheme.

2.3 Data

We obtained information about the total funds sanctioned under each NRHM MCH activity in a given financial year from records of meetings conducted for central government approval of state programme implementation plans [29]. The amount of budget spent for each NRHM activity was obtained from financial monitoring reports from 2005–2006 to 2012–2013. Financial monitoring reports are financial statements that have been thoroughly audited by an external agency and thus serve as proof of expenditure. The implementation status of the various MCH activities was obtained from yearly NRHM progress reports for Haryana [30]. The status of MCH indicators before, during and after the NRHM (2002–2004, 2007–2008 and 2012–2013, respectively) implementation period was obtained from national demographic surveys, i.e., district-level household surveys (DLHS) [31,32,33].

2.4 Data Analysis

The budget utilization rate for each NRHM health plan was estimated as the proportion of expenditure incurred relative to the budget sanctioned for implementing the MCH plan. A conversion rate of $US1 equivalent to 62 Indian rupees (2013–2014) was used. The MCH plan was considered fully implemented if the budget utilization rate was ≥100%, partial if the rate was 1–99% and nil if the rate was <1% at the end of the 2012–2013 financial year. Partial implementation was further categorized as high (80–99%), mid (20–79%) and low (1–19%). Trends in MCH indicators before, during and after NRHM were observed and compared using a Chi squared test. p values <0.05 were considered significant. MCH indicators were carefully chosen from DLHS reports using a logic model (input-process-output-outcome/impact indicators); the purpose was to include those indicators most likely to have been affected by the NRHM MCH strategies [34]. For example, when implementing the financial incentive scheme for pregnant women, the availability of funds is the input, the number of women registered under the scheme is the process, and the number of registered women who availed themselves of this scheme and delivered in an institution was the output indicator. Furthermore, these MCH indicators represented the major aspects of the preventive (e.g., registration of pregnant woman in the first trimester, three or more antenatal check-ups, tetanus immunization, fully immunized children, institutional delivery rate, etc.) and treatment-related (e.g., children with diarrhoea who received oral rehydration solution) interventions intended to improve MCH.

A correlation analysis between MCH indicators (such as number of patients referred through referral transport, the number of pregnant women registered under the financial incentive scheme, the institutional delivery rate, the availability of accredited social health activists, the immunization status of children) and the respective budget utilization rates was also conducted.

3 Results

Table 1 shows the total amount of budget sanctioned and spent to implement the NRHM health sector plans from 2005–2006 to 2011–2012. The sanctioned amount increased from $US6.6 million in 2005–2006 to $US66.7 million by 2012–2013. The budget utilization rate decreased during 2006–2008 but increased thereafter (Fig. 1). Financial monitoring reports regarding the implementation of NRHM schemes were available from the year 2007–2008 onwards. Table 2 presents the yearly allocation of funds, expenditure incurred and the budget utilization rate under each scheme from the financial year 2007–2008 to 2012–2013. The state initially focussed on strengthening the health system, mainly through the provision of drugs and logistics, as indicated by the budget allocated to these schemes in the initial year. Subsequently, infrastructure was strengthened, more human resources were promoted and referral services were introduced. For the communitization strategy, the main focus was on implementing the scheme to recruit accredited social health activists. Although the state initially implemented the village health nutrition scheme, it appeared unable to maintain it. From the year 2008–2009 onwards, planning under NRHM improved considerably, with funds being allocated to other schemes relating to health system strengthening, communitization and MCH components.

Table 1 Total funds received and spent ($US millions) on implementing maternal and child health sector plans under the National Rural Health Mission for the financial years 2005–2006 to 2012–2013 in Haryana
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Fig. 1
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Trend of budget utilization rate of maternal and child health sector plans under National Rural Health Mission from financial year 2005–2006 to 2012–2013 in Haryana, India

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Table 2 Year-wise distribution of budget sanctioned, expenditure incurred ($US million) and budget utilization rate (%) for the National Rural Health Mission maternal and child health sector plans for the financial years 2007–2008 to 2012–2013
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Figure 2 provides a comparison between the components (e.g., health system strengthening, communitization, MCH strategies). Overall, the budget for implementing communitization and health system-strengthening strategies was fully utilized, followed by MCH strategies. Funds were over-utilized for patient transport services (115%), human resources (110%) and drugs and logistics (170%), under health system strengthening in 2012–2013 (Fig. 3). Under communitization, the state over-spent on social health activists (133.3%) and patient welfare committees in hospitals (112.5%) (Fig. 4). For the maternal healthcare strategy providing financial incentives for institutional deliveries, the rate of budget utilization increased steadily from 0.8% in 2007–2008 to 80% in 2012–2013 (Fig. 5). Under child healthcare strategies, the rate of budget utilization increased from 0 to 37.5% for the integrated management of neonatal and childhood healthcare, and from 66.7 to 106.4% for immunization (from 2005–2006 to 2012–2013, respectively) (Fig. 6). For the home-based newborn care scheme, budget utilization increased drastically from 7.7% (2011–2012) to 485.7% (2012–2013). The budget utilized to implement national rehabilitation centres was minimal at 0.6%.

Fig. 2
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Comparison of budget utilization rate of health system strengthening, communitization, maternal and child healthcare strategies components of National Rural Health Mission from 2007–2008 to 2012–2013

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Fig. 3
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Trend of budget utilization rate under health system strengthening component of National Rural Health Mission from 2007–2008 to 2012–2013

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Fig. 4
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Trend of budget utilization rate under communitization component of National Rural Health Mission from 2007–2008 to 2012–2013

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Fig. 5
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Trend of budget utilization rate under maternal healthcare strategies of National Rural Health Mission from 2007–2008 to 2012–2013

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Fig. 6
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Trend of budget utilization rate under child healthcare strategies of National Rural Health Mission from 2007–2008 to 2012–2013

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The state’s NRHM progress report indicated that the number of health facilities and healthcare providers increased (Table 3). Table 4 summarizes the extent of NRHM plan implementation on the basis of the rate of budget use for various MCH schemes. Schemes that were fully implemented included the referral transport service; the availability of human resources, drugs and logistics; the accredited social health activists scheme; the patient welfare committees scheme; the immunization scheme; and the home-based newborn care scheme. The nutrition rehabilitation centre scheme and village health nutrition days were only minimally implemented, and most of the other schemes were partially implemented.

Table 3 Status of health facilities and healthcare providers in Haryana [30]
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Table 4 Status of implementation on National Rural Health Mission maternal and child health sector plans in Haryana
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Implementation of the communitization component was better than that of others, with two of its strategies—accredited social health activists and formation of patient welfare committees in health facilities—fully implemented. The village health and sanitation committees were partially implemented (mid-level). Similarly, the health system strengthening component was also well implemented, with three—human resources, provision of drugs and logistics and patient referral transport services—of six strategies fully implemented and infrastructure development partially implemented (mid-level). Child healthcare strategies were better implemented than the specific maternal healthcare strategies, with both home-based newborn care and immunization strategies but none of the maternal health schemes fully implemented.

MCH indicator trends before, during and after the NRHM period improved significantly (Table 5). The rate of institutional deliveries increased significantly from 35.7 to 77%. The MMR decreased from 1.85 (2002–2004) to 1.21 (2012–2013) per 1000 live births at the state level, and the IMR decreased significantly (p < 0.05) from 59 to 40 per 1000 live births.

Table 5 Status of maternal and child health indicators pre, during and after implementation of the National Rural Health Mission in Haryana as per district-level household surveys rounds 2, 3 and 4
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A strong positive correlation was observed between the increase in institutional deliveries and the rate of budget use to implement the accredited social health activists scheme (r = 0.96), and a moderate correlation was also observed with the financial incentive scheme for pregnant women (r = 0.5) over the years. Positive correlations were observed between the rate of budget utilization for the social health activists scheme and the corresponding number of health activists (r = 0.44) and between the financial incentive scheme and the corresponding number of beneficiaries registered under this scheme (r = 0.3). A negative correlation was observed between the budget utilization rate for immunization and fully immunized children (−0.79). However, these results were statistically non-significant (p > 0.05) because the estimates were conducted over limited time periods (because of the lack of available MCH output indicators from periodic surveys: DLHS rounds 3 [2007–2008] and 4 [2012–2013] and UNICEF coverage evaluation survey, 2009) (Table 6).

Table 6 Correlation between budget utilization rate and maternal and child health services/indicators
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4 Discussion

The results of this study indicate an overall trend for an increasing use of budgets for NRHM MCH strategies in Haryana from 2007–2008 to 2012–2013. Simultaneously, MCH indicators improved significantly during and after compared with before the NRHM period. This indicates improvements in the implementation of MCH strategies over these years. The patient referral transport services, human resources, drugs and logistics, accredited social health activists, patient welfare committees and immunization strategies were fully implemented. However, overall, the NRHM maternal and child health sector plans were only partially implemented in Haryana, which may explain the slow pace at which millennium development goals are being achieved.

The rates of budget use for implementation of the NRHM MCH sector plans vary widely from financial year 2005–2006 to 2011–2012. This is because, initially (2005–2006), funds were allocated as per the reproductive and child health (RCH-II) programme. Under this previous programme, fewer funds were available for the health system strengthening and communitization components as it mainly focused on implementing specific MCH plans. However, utilization of the funds was high because of the health sector reforms (e.g., decentralization) in RCH since 1999 in the state [35]. In later years, the planning and budgeting for additional NRHM interventions (e.g., infrastructure development, human resources, patient referral services, accredited social health activists linking the community and the health facility, patient welfare committees, financial incentive schemes for pregnant women, increased delivery points, and trained human resources to implement integrated management of neonatal and childhood illnesses) considerably increased the sanctioned budget. The utilization rate was only 20% during 2007–2008 but increased to almost 100% by 2011–2012. The change in leadership during 2009 (i.e., a new Mission Director joined the state) might also have contributed to this change. Under his stewardship and vision, the state annually not only received more budget but also increased utilization. Brinkerhoff and Bossert [36] emphasized that good governance is crucial for the strengthening of the health system. This is also demonstrated locally, where reforms for decentralization in Haryana between 2002 and 2004 were strongly influenced by improved local leadership [37]. Hence, the ruling government has a role in influencing the public health expenditure at different levels within the state; this was also documented in China [38].

Haryana state focused on implementing some of the aforementioned key interventions, such as providing free patient transport services; increasing human resources, drugs and logistics; appointing a local woman as a social health activist (a woman resident in the same village in which she was appointed had studied at least till eighth standard) eighth standard (i.e., till first year of high school), and married to a husband belonging to that village) as a link between the community and the health facility; and trained human resources to implement integrated management of neonatal and childhood illnesses. However, it also needed to place more emphasis on developing and strengthening infrastructure, creating 24-h delivery services, enabling treatment of sick children at health facilities, and implementing communitization activities. The improvement in MCH indicators, particularly the institutional delivery rate (from 46.9 to 76.9%), could be because of the better implementation of NRHM schemes (e.g., referral transport, financial incentives for institutional deliveries and the appointment of accredited social health activists in villages) that focus on improving institutional delivery. Prinja et al. [39] also reported positive effects from a referral transport service, and Jain et al. [15] found positive effects from health activists in terms of increased numbers of deliveries in institutions. Financial investments in public health have the potential to improve community health [40], and a direct correlation between the level of public health spending and its impact on improving equitable utilization of health services has also been reported for India [41].

As per the logical framework model using input-process-output-outcome/impact indicators, we assumed that the proportion of allocated budget actually utilized was one of the inputs for improving MCH outcomes [34]. Also, as per the World Health Organization (WHO) framework of health system building blocks, health financing is one of the major building blocks of the health system [23], building and strengthening other building blocks such as the health workforce, infrastructure and supplies. If programme implementation plans are well prepared and executed, budget utilization rates can provide a good indication of the status of plan implementation. Districts were required to prepare action plans for all MCH activities to be implemented in the next financial year. These budget plans were then compiled at the state level and sent to central government for funding. The central government sanctioned the funds on the basis of the rate of budget utilization from the previous year and proper justification of the plans for the next year [42]. Therefore, a kind of blueprint existed for the budgetary outlay before implementation of the MCH plans at the beginning of a given financial year. These budgets had to be used for implementation; if not, fewer funds could be allocated for the following year. Therefore, at the end of the financial year and for any activity, the budget sanctioned can be compared with the budget used to provide a reliable proxy for complete or incomplete implementation of the activity [43]. Similar budget estimations were also conducted to study the healthcare financing system in Sierra Leona, Africa [44]. Our study adds to the existing literature, as earlier evaluations of NRHM did not investigate fund allocation and utilization patterns for MCH schemes [13].

It is possible for health outcomes to only show minimal improvement despite full utilization of the budget for a given activity. Our study found that only 52% of children were fully immunized in the year 2012–2013, despite full use of the budget for this strategy (105%). This indicates the presence of other factors that could not be directly controlled by just spending money, which could include the arrival of families with unimmunized children from neighbouring states, lack of trained vaccinators and poor acceptance of the strategy in the community. Hence, after 2013, budget allocation was started on the basis of performance indicators rather than on the budget utilization rate in India.

The results of this study provide new insight into the use of intergovernmental funds to implement NRHM MCH plans, which has not previously been documented in India. It also delineates the state’s priorities in implementing such schemes. Increased budget use correlated well with improved MCH indicators during the NRHM implementation period, further strengthening our findings.

Our findings raise several issues related to the over- or underutilization of funds. Possible explanations for discrepancies in utilization compared with the allocated budget could include inadequate budget estimation, inadequate registration of actual costs incurred, more efficient resource use than originally planned, or less money spent on MCH, leading to an insufficient decline in maternal and child mortality.

Underlying reasons for partial implementation and underutilization of the budget could include insufficient capacity of the state to spend the budget or late release of funds by central government. States usually send the programme implementation plans in the last quarter of a financial year (January–March), and the budget is approved in the first quarter of the next financial year (April–June), after which it is released in either the second or the third quarter. This leads to a last quarter rush, as reported by Gupta et al. [42] and Fan et al. [45]. Further reasons for underutilization might include improper planning for implementation of activities (e.g., the activity is implemented at the end of the year); inadequate number of programme managers (e.g., one programme manager looking after many programmes); different priorities set by the state, leading to one plan being prioritized over another; and a lack of regular monitoring and supervision of the implementation of activities and the utilization of funds [46]. Common and joint review mission reports have also documented partial implementation of NRHM activities and reported that scope for improvement certainly exists. Overutilization of funds on certain schemes could be because of the flexibility of NRHM funds and because the state could choose to provide additional funds from the state’s health budget. Unsynchronized budget and expenditure cycles that lead to a delay in budget execution and complications in programme implementation has also been documented in China [47]. This study did not assess district-level variations in budget expenditure and utilization in implementing NRHM plans; this warrants further study.

One limitation of this study is that the role of confounding factors, such as improved socioeconomic conditions and their relationship with MCH indicators, cannot be ruled out. It is also difficult to comment on the effectiveness of budget utilization, as that depends on simultaneous measurement of MCH outcomes and was not the objective of this study. We investigated the surrogate parameter budget spent on state-level MCH care, but it would be better to evaluate actual care. Underlying our argument is the assumption that all separate measures and the budget allocated to them are equally important for the reduction of maternal and child mortality. More research is warranted to find out whether some measures with different budgets allocated and used might be more effective than others. One could even speculate whether a model could be made that estimates the actual care on the basis of measured budget spent. A prospective field survey to simultaneously look at budget use, the implementation process and the outcomes may also be conducted to investigate the effectiveness of the budget used to improve MCH outcomes. However, this is costly and time consuming, and lack of funding and inadequate timeframes are major barriers for comprehensive health system evaluations in low- and middle-income countries [48]. The advantage of our indirect method is the feasibility and ease with which existing information could be used to ultimately improve implementation of future health plans.

5 Conclusions

Our findings provide important insights into how the state uses national funds (intergovernmental funds) to implement centrally funded (large) programmes such as the NRHM. Our findings might be useful for policy makers and programme managers as they can be used to improve planning and implementation of the national MCH programme. The budget utilization rate can be used to monitor successes and failures of the national programme and its components. Our findings might also assist other low- and middle-income countries when thinking about how to implement and evaluate national programmes.