The budgetary allocation for Saharsa and the total funds received remained almost constant over 2018-19 and 2019-20. The total pool of funds available for Saharsa increased from Rs 85 crore in 2018-19 to Rs 94 crore in 2019-20 (Figure 1). This indicates a greater pool of funds was available for spending by the district to improve various health outcomes prior to the pandemic year itself.

Figure 1: Availability of Funds under NHM for Saharsa (Rs crore)

• • While the allocation to the district has remained constant, spending increased by around 13% in 2019-20 across different health institutions in the district (Figure 2), translating into a better utilisation rate.
• The flow of funds has occurred significantly from the district health society to various actors at the Block/PHC level. However, there’s only a marginal increase at the sub-district level, suggesting that proper attention has not been paid to address various health issues at the primary level in spite of availability and timely disbursal of funds in the past two years.

Figure 2: Utilisation of Funds under NHM in Saharsa (Rs crore)

• The extent of funds utilised out of the total funds received during the year has been better for Saharsa subdivision (which consists of 7 blocks/PHCs, including Saharsa District Hospital) vis-à-vis the district average, as compared to the Simri Bakhtiyarpur subdivision (which consists of 3 blocks/PHCs) in the last two years (Figure 3).

Figure 3: Block-wise Extent of Funds Utilised out of Total Funds Received During the Year in Saharsa (%)

• Figure 3 also shows a significant variance in fund utilisation by PHCs at the block level. Six of the 10 PHCs exceeded the district average in 2018-19, which decreased to only 4 in 2019-20. Such under-utilisation of funds at the sub-district level in Saharsa may adversely impact the achievement of primary healthcare outcomes in the district.
• Analysing the component-wise utilisation rate in Saharsa, a very low share of the overall fund disbursal occurs from the District Health Society (DHS) to various implementing agencies under NHM. This has resulted in a low utilisation rate of funds vis-à-vis PHCs at the block level.
• Among implementing agencies, the highest utilisation rate was for the Revised National Tuberculosis Control Programme (RNTCP) in 2018-19, which though declined considerably in 2019-20. Although RCH is a significant component of NHM, its fund utilisation was the lowest across both years. This indicates the district administration has yet to prioritise maternal and child healthcare, which has been done somewhat in 2019-20 (Figure 4).

Figure 4: Extent of Funds Utilised out of Total Funds Received During the Year by Implementing Agencies under NHM in Saharsa (%)

NHM has 18 sub-components under which allocations are made to cater to the needs of different sections of the population in a holistic manner and ensure last-mile service delivery by strengthening the overall health infrastructure in the country. These are: (1) Service Delivery (Facility Based), (2) Service Delivery (Community Based), (3) Community Interventions, (4) Untied Funds, (5) Infrastructure, (6) Procurement, (7) Referral Transport, (8) Human Resources, (9) Training and Capacity Building, (10) Review, Research, Surveillance and Surveys, (11) Information Education Communication (IEC)/Behaviour Communication Change (BCC), (12) Printing, (13) Quality Assurance, (14) Drug Warehousing and Logistics, (15) Public-Private Partnership (PPP), (16) Programme Management, (17) IT Initiatives for strengthening Service Delivery and (18) Innovations (if any).

A detailed analysis of PIPs and RoPs of Saharsa shows the major chunk of allocation over the years has gone to facility-based service delivery, community interventions and procurement (Figure 5). The two components of programme management and infrastructure need a substantial hike in allocation vis-à-vis other components to ensure effective service delivery for the people in Saharsa.   

Figure 5: Share of Budgetary Allocation for Saharsa under Major Sub-Components of NHM (%)

• Institutional Deliveries: Maternal healthcare is majorly dependent on availability and accessibility of public health facilities in Saharsa. Deliveries at public health facilities in Saharsa exceed the state average and have been increasing. This share is even higher for public health facilities that grant financial assistance to mothers under the Janani Suraksha Yojana (JSY) of NHM (Figure 6). This has been achieved possibly due to the higher spending rate by the RCH office in 2019-20.

Figure 6: Institutional Deliveries in Saharsa (%)

• Incidence and Safety of Home Deliveries: Figure 7 shows that in spite of adequate public provisioning to facilitate institutional deliveries, a considerable share of pregnant women in Saharsa preferred home deliveries to institutional deliveries. However, a very low share of such home deliveries are attended by Skilled Birth Attendants (SBA), increasing the risk of mortality/other complications due to unsafe home deliveries. Thus, adequate provisioning of resources to facilitate safe home deliveries is required.

Figure 7: Incidence and Safety of Home Deliveries in Saharsa

• Treatment of anemia: As per HMIS (2019-20) data, only 21.3% severely anaemic pregnant women in Saharsa received treatment at public health facilities, as compared to 38.9% in Bihar. Thus, adequate provisioning for anaemic women should be prioritised under the RCH component of NHM.

• Family planning measures adopted by women: As per NFHS (2015-16), Saharsa had a higher share of women (28.4%) than the state (23.3%) who used any modern method of contraception. Further, this improved in 2019-20 due to higher utilization of funds under the RCH component of NHM. Yet, there existed an overall ‘unmet need’ for family planning of 16.7% in Saharsa as compared to 13.6% in Bihar in 2019-20 (NFHS-5; 2019-21), for which appropriate allocations need to be made.
• Role of ASHA in promoting family planning measures among women:  As per NFHS, around 22% female non-users were contacted by health workers (ASHAs) in 2019-20 as compared to 18% in 2015-16. These figures are above the state average (12% in 2015-16 and 20% in 2019-20). This shows that ASHAs have played a key role in promoting family planning measures in the district. This can be attributed to the priority given to the allocation for ASHA incentives under the following awareness programmes: Mission Parivaar Vikas (MPV) Campaign, Ensuring Spacing at Birth (ESB) Scheme and Antara Programme over the past few years.

• New-born and infant care: As per NFHS, breastfeeding practices for children under 3 years of age (within one hour of birth) increased significantly for the district from 26% in 2015-16 to 38% in 2019-20. The corresponding state averages were 35% and 31%, respectively. This improvement in district performance follows the increase in fund utilisation under the RCH programme and facilitated through the Mothers Absolute Affection (MAA) Programme over the past few years.
• Incidence of malnutrition: Figure 8 shows the incidence of malnutrition is very high for both Saharsa and Bihar during the last few years, especially among stunted and underweight cases. Fund allocation needs to be prioritised under the RCH Programme in the district.

Figure 8: Incidence of Malnutrition in Saharsa (%)

• Child Immunisation: Saharsa has done better in child immunization than in other health indicators, bettering the state average in both 2015-16 and 2019-20 (Figure 9). A greater number of sessions were held across the district, and most children (age 12-23 months) received their vaccinations in public health facilities (98.8% in Saharsa as compared to 96.6% in Bihar in NFHS-5: 2019-20). The above could be possible because of enhanced support and initiatives by the district administration towards child immunization programmes. However, the concern lies in the decreased share in 2019-20.

Figure 9: Share of Children (12-23 Months) Covered by All Basic Vaccinations in Saharsa (%)

• Treatment of common diseases among infants and children: A marked improvement can be seen in the treatment of childhood diseases such as diarrhea (47.6% in 2015-16 to 71.3% in 2019-20) and fever (64.9% in 2015-16 to 75.5% in 2019-20) for children under 5 years of age in the district who were taken to nearby public health facilities, which is way above the state average. This improvement has been seen due to the high rate of utilisation of funds under the District Malaria Officer (DMO) in the district over the past two years.

• Although fund utilisation was quite high under the RNTCP cell in 2018-19, the annual notification rate of TB cases has been only around 50% in Saharsa (Annual TB Report 2018). This indicates that funds have not been utilised efficiently to ensure effective case management of TB patients.
• A major concern related to non-communicable diseases has been the high consumption of tobacco by men, which is around 55%, as per NFHS (2019-21). Yet, there’s no focused action towards prevention and control of non-communicable diseases in the district, as is evident from nil budget utilization in 2019-20 as compared to around 62% in 2018-19.

The present factsheet has used data/information provided in the State Programme Implementation Plans (SPIPs) and Records of Proceedings (RoPs) for 2018-19 and 2019-20. For outcome indicators, data has been sourced from the National Family Health Survey (NFHS) for 2015-16 and 2019-21, and from Health Management Information System (HMIS) reports for 2017-18, 2018-19 and 2019-20.

Given the importance of NHM in providing affordable healthcare to a large section of the populace, different data/information about the scheme should be readily available and accessible to the common masses. Figure 11 lists essential NHM data points/information that are useful to various stakeholders for Saharsa. Hence, their availability and accessibility would be useful. The current level of information available has been evaluated as under:

Transparency and Accountability Index

Availability of Information and Comprehensiveness

Information on funds available

Yes

Information on funds utilized

Yes

Information on eligible beneficiaries under various sub-components of NHM

Yes

Gender-wise disaggregation of beneficiary data

No

Caste-wise disaggregation of beneficiary data

No

Geographical granularity of the fiscal indicator

Fund availability: Available Block/PHC-wise and component-wise

Expenditure of funds: Available only Block/PHC-wise and not component-wise

Information on number of PHCs/DH/SDH

Yes

Accessibility

Language in which information is available

English only

Compatibility on devices

Phone, tablet, laptop friendly

Timeliness

How frequently is data updated?

Yearly

Relevance

How relevant would users find it?

(i) Fiscal information pertaining to the budget approved/allocated is extensively available in state/district PIPs and RoPs for various years by components, but it is not aligned with the geographical granularity of the district. Expenditure data for various years is available only by geography and component, making it difficult to arrive at an aggregate picture of health sector spending in the district.

(ii) Data sources pertaining to various health outcomes, such as NFHS and HMIS, are quite extensive in their coverage and in providing adequate information in the public domain.

Reliability

Is the data reliable?

Relevant audit reports are not available on the NHM website. Hence, reliability of data has remained an issue.

Accountability and Citizens' Participation

Availability of information on social audit

Provisions for the same are not available on the NHM website.

Availability of information on grievance redressal

Provisions for the same are not available on the NHM website.

• Although overall utilisation has increased in the last two years, it’s highly uneven across blocks/PHCs in the district, adversely impacting key health outcomes in the district. This might have occurred due to inefficient allocation of resources to human resources, physical infrastructure, and procurement of drugs and equipment under various components of NHM.
• Saharsa has been a priority district in terms of allocation of funds under NHM, especially in the pre-pandemic years. However, unavailability of corresponding expenditure data at the granular level (both geography-wise and component-wise) has severely limited a comprehensive analysis of public provisioning vis-à-vis health outcomes in both pre- and post-pandemic years.
• Some areas where the district has performed fairly well are child healthcare and treatment of childhood diseases, child immunisation, facilitating of institutional deliveries and institutional sterilisation.
• However, high incidence of anaemia among pregnant women and malnutrition among children are areas that require high budgetary priority to achieve overall welfare of vulnerable sections such as children and women in the district.
• Besides the above, more funds should be allocated towards capacity building of health workers and expanding and equipping public health institutions with state-of-the-art facilities in the district so as to further improve health outcomes in the district.