Context

Maharashtra is the second most populous state in India, with 45 percent of the population residing in urban areas.¹ The health care system has seen significant progress against the backdrop of high economic growth and progressive social reforms, although it has been limited in recent years with declining state health expenditure.

Strong Economic Growth

Maharashtra contributes 14.4 percent to the nominal gross domestic product (GDP) of India,² the highest in the country, due to its high industrialization and urbanization. The state constitutes less than 10 percent of the national population but accounts for nearly one-fourth of the gross value of India's industrial sector.³

Although the state has seen exponential economic growth because of its liberal economic policy and conducive environment for business and industries, this growth has been largely uneven. Maharashtra's promising economic growth is largely driven by the state’s high GDP contribution from the Konkan, Pune, and Nashik divisions, and particularly that of Mumbai, which contributes 15 to 20 percent of the state’s GDP.3 Excluding Greater Mumbai and Pune division, the rest of Maharashtra would have similar economic growth levels as Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh.⁴  Despite the uneven growth, Maharashtra has improved health outcomes, which could be influenced by high per capita income concentrated in regions and overall industrial modernization.

Progressive Social Reforms

Maharashtra, with its rich history of stable governance and social movements, figures prominently in the history of several social reforms in India. Movements such as the Satyashodhak Samaj (a social reform society focused on education, social rights, and political access), assertions of underprivileged castes, and labor groups with participation from political parties have established a base for progressive change and development in the state.

As early as 1961, Maharashtra decentralized health care and gave Zilla Parishads the autonomy to implement health care, education, and other social programs. Zilla Parishads received grants under the Maharashtra Zilla Parishads and Panchayat Samitis Act to carry out programs and services including vaccinations, school health clinics, and other primary health care services. Maharashtra made giant strides toward a more inclusive and independent governance structure that paved the way for progressive health care policies and an elaborate health care infrastructure in the decades to come.

The impact of this shift in governance was apparent in the 1980s when Maharashtra became one of the first states to expand its rural health care infrastructure by establishing a primary health center (PHC) to serve 30,000 people and a subcenter to serve 5,000 people. Today, the average population covered per subcenter, PHC, and community health center in Maharashtra is 5 to 15 percent more than the national average.⁵ Maharashtra’s human resources for health care also witnessed steady growth, with major acceleration in the 1990s when the number of doctors per population was 36 percent higher than the national average.

In addition to social reforms, the success of the polio program informed subsequent public health policy. Several best practices and learnings from the polio campaign, such as supervised drug administration, were adopted by many public health interventions including the lymphatic filariasis response.

Despite its progressive indicators, however, the distribution of Maharashtra’s health facilities reflects a wide gap between rural and urban areas, both quantitatively and qualitatively—similar to its uneven economic growth trends.

Declining State Budget

State funding for disease control programs experienced a steady decline after the 1990s, but it is now supplemented by central funding to ensure effective delivery on the ground.

In the late 1990s, Maharashtra significantly cut down on its health expenditures to reduce the fiscal deficit. Health care spending by the government decreased from over 6 percent in the 1980s to less than 5 percent in the 2000s. During this time, India’s national disease control programs also saw a decline in their funding due to the central government’s decision to cut down financial transfers to states. The state’s health budget has gradually declined since the 1990s, which affects program delivery for state-led public health programs.

Despite the decreasing health budget, programs for life-threatening diseases such as malaria remain unaffected due to international funding from the Global Fund and the World Bank. Similarly, the Elimination of Lymphatic Filariasis program was funded by the National Health Mission, which helped offset the decrease in state spending.