The National Health Policy 2017: Through the Accountability Lens (Concluding Part)

V. Private Sector Engagement

One section of the policy deals with the engagement of private sector for critical gap filling towards achieving national goals. The engagement proposed has two aspects. One is collaboration and second is the encouragement (incentive based and non-incentive based).

Collaboration is proposed for primary care services and domain based specialized human resources and organizational experience. Encouragement of private providers through creating opportunities for skill up-gradation, participation in surveillance and disease notification and sharing in high-value services such as high-tech labs are proposed as the key strategies. The policy supports volunteerism from recognized health care professionals on a pro-bono basis. The CSR initiatives in preventive and primary care are seen towards contributing to the public good.

To encourage private finance and investments, the NHP 2017 proposes the basic principle of adequate returns on commercial terms that will be assured through contracting and strategic purchasing. The mechanisms of incentivizing private sector would include reimbursements, preferential treatment in empanelment for government health insurance schemes, non-financial incentives such as recognition, and preferences in procurements.

The more relevant point for this section of the policy is that within a profit-maximizing framework, corporate responsibility for healthcare from private sector is always contingent and provisional. Pro bono contributions require an eco-system, and autonomy at the institutional level. The outcomes of pro bono system are not always sustainable but speculative and situational. Any action that may be withdrawn whenever economic conditions change, the system is not based on responsibility but speculation.

Over the years, India has adopted a health care financing system that provides financial protection to a targeted segment of BPL population. A significant part of the population, particularly above poverty line groups, continues to lack access to minimally adequate health services. Health care financing policies in India have tended to widen rather than reducing the gulf between privileged and underprivileged and between rural and urban populations.

The policies over the years have created a significant dependence on the unregulated private sector. Indian health care utilization patterns reflect major influences and preference towards private healthcare sector. The interaction and engagement with the private sector if implemented will happen through a decentralized administration separated at various levels and that too through a highly fragmented responsibility system. It is possible that the evolution of health care financing mechanisms in India will follow, for better or worse, the general experience of the countries having a high dependence on private sector along with the policy dilemmas imposed by aspects of Indian geography, socio-economic situation, and the political economy. Some of the predictable implications are the critical moral hazard from both provider side and no relief from high OOP expenditures. So the policy dilemma we face is what should be the structure of institutional mechanism and administrative processes that should be instituted to strengthen the private sector engagement.

India adopts a sort of free-market system in health care. We have minimum regulations in the health care promoting the concept of medical specialization rather than creating a network of primary care physicians linked through referral system to higher levels of care. Primary care in the process has taken the back seat. Given this, there does not exist appropriate mechanisms for ensuring early detection of health risks. We allow health risks to aggravate and then it fills the demand for specialists. There are no appropriate referrals because of the kind of incentives we have developed in the health sector. The professional barriers have been huge by not allowing alternative forms of health care provision. It is always challenge to break the existing shackles and move forward.

The most parameters of health infrastructure such as doctor-population ratio, hospital beds to population ratio, etc. remain quite unfavorable. What should be the appropriate policies that help in improving the supply of medical infrastructure, promote the development of medical resources in the right areas, change health care delivery methods? Inequitable distribution of services will hamper achieving the health goal.

India should find the real foundation of rationalization of policy, particularly engaging with the private sector. India has far lesser health resources than many other nations, and we face a real risk of India becoming a place of unnecessary procedures, waste, costs and mal-distribution of medical care provision. The consequences of this may be severe, particularly when unmet needs of a large segment of the population remain high.

The argument that through the engagement of private sector, we will be able to reduce the market failure and promote harmony automatically is misplaced. It is recognized that such policies consist of inherently conflicting interest and in the absence of appropriate institutional processes it will be difficult to address this. The private sector is so fragmented, representing diverse groups who do not operate on a level playing field which will create its own problems.

The NHP 2017 provides us an opportunity to initiate an in-depth examination of anticipated implications of market-based health care financing approaches. The way health care financing mechanisms are approached, with a significant absence of the role of institutions in their implementation and increasingly over-engagement with the private sector and the design of health care provisioning with a weak and fragmented government control, we need to look into challenges seriously. However, following any particular approach is always consequential, but never more so than in the case of examining options in India today.

Accountability Towards Implementation

There is urgency to implement what has been said and also thinking through issues raised here. The policies evolve, and we have an opportunity to contribute to its development further.

The existing state of health in the country is in so much of need that any attempt to improve the present position must necessarily involve measures of enormous magnitude. The action has to follow, and promises have to be fulfilled which definitely are out of all proportions to what has been conceived and articulated.

The release of the policy document should not be seen an end in itself and treat this as one of the milestones towards its announcement. On the responsibility to implement the national health policy, Bhore Committee had stated:

It is not for us to apportion responsibility for the somber realities, which face us today. It is with the future that we are concerned and, if the picture is to be substantially altered for the better with the least possible delay, a nation-wide interest must be aroused, and the irresistible forces of an awakened public opinion essayed in the war against disease. Only a vivid realization of the grievous handicap, which is today retarding the country's progress, can help to mobilize an all-out effort in this campaign and infuse into it a driving force, which will gather and not lose momentum as time goes on. If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about.

If the health care is a matter of the broad public interest, then policies must reflect defined accountability as well as the commitment of assigned resources, on which the NHP 2017 deserves to evolve further.

The National Health Policy 2017: Through the Accountability Lens (Part 4)

IV. Health Finance

In the absence of a real resource commitment to implement the policy, any strategy is a statement of dreams.  Asking pointed and relevant questions on the resource envelope and how the proposed activities are going to be financed can help discerning the real intent of the policy.

The NHP 2017 sets three targets for health finance: (a) increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5 % by 2025, (b) increase State sector health spending to > 8% of their budget by 2020 and (c) decrease in proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.

Our budget allocations go through an elaborate process of vetting and approvals by the Niti Aaayog and the Ministry of Finance. The complexity of this resource allocation is well known. Health is a state subject and gradual phasing of centrally sponsored programmes, the success of any strategy hinges on the contributions made by states to the overall resource envelope. Given the fiscal position of several states, there would be a huge challenge for the states to prioritize the health, even though they now receive higher untied allocations from the centre. NHP 2017 is silent of this dynamics.

It may be noted that the policies and government pronouncements in the past had strongly advocated for an increase in public expenditure on health. The important question in NHP 2017 context is what is the government plan to make this happen and whether there would be a way to institute accountability on states to draw the resource envelope in a desired manner. The NHP is not explicit on this and the promises made in the past.

The policy advocates allocating major proportion of the resource envelope (up to two-thirds or more) of resources to primary care. The existing budgets are too committed to grant any scope and flexibility for the reallocation of resources. So this would be possible only if new additional untied resources are generated, and, therefore contingent upon the resource generation strategy about which the policy takes a perfunctory view without defining appropriate responsibilities.

With the baggage of huge neglect of primary care and too much dependence on hospitals, the health system has gradually drifted towards emphasizing expensive, overspecialized care making resource envelope too rigid. The lack of investments in primary care and also on public health precludes a referral system and addressing health risks at an early stage. The coordination between primary care and government health insurance schemes focusing on only hospitalization remains weak as the institutions and administrations in government handling the GHIS and primary health remain administratively separated. Further, the lack of coordination between and within programmes compounds the issues. The policy has not immersed deep to take an integrated view on this and how the system needs to be set right.

It is well established that the application of Cost-Effectiveness Analysis (CEA) methodology provides justification for making appropriate choices for the health sector. At present its use is limited in the health decision making. In fact we have compromised on the introduction of new and expensive technologies as many medical interventions have been introduced over the years without doing appropriate and contextual CEA. As a result, we have adopted practices responsible for passing on an increasing proportion of costs to patients leading to the high OOP expenditures on health. 
The recent example of cardiovascular stents is an example.

The NHP 2017 takes a clear view on inclusion and prioritization on the basis of cost-benefit and cost-effectiveness analysis in programme design and evaluation. This would contribute significantly to increasing efficiency of public and private expenditure. 

However, we will need adequate resources and attention for putting the appropriate institutional structure, capacities and processes in place. The focused efforts among other things should also address issues of standardization of methods, addressing various biases that may creep in such analysis and keeping the reviews objective and free from different vested interests. Along with the capacity building, the strategy would also need developing collaborative linkages across various institutions and making the participation of health economists and other disciplines possible, away from medico-centric approach, in such initiatives. Engagement with stakeholders such as IRDA and insurers who have a vital interest in this area must contribute to this effort and institute framing guidelines for making the CEA of interventions a mandatory requirement for all health interventions.

The policy proposes that a robust National Health Accounts System would be operationalized to improve public sector efficiency in resource allocation/payments. The state-level health accounts methodology and studies based on this have served the purpose of informing the policy makers about the seriousness of OOP expenditures on health. Improving efficiency of the public sector is much more complex and multi-dimensional and needs strategies beyond health accounts methodology.

The NHP 2017 has outlined reforms in financing for public facilities. The proposal is to bifurcate the costs in two buckets - operational costs and establishment costs. The later will continue to flow as it is, but the former will be now on reimbursement based. In the absence of budgetary control system and performance based evaluation, it is not clear how this system of bifurcation will work in real practice. The health establishments across the board will remain contended to receive fixed component (such as salary) and not raise any concerns for not receiving resources for operations. What will be the game changer here? The system does not ensure that the existing inefficiencies embedded in the system today will not be carried forward. In the absence of autonomy and appropriate performance accountability system linked to illness burden and public health responsibilities, the mere tinkering of costs have little reform potential. A comprehensive view of public facility autonomy and accountability of which cost classification could have been an integral part of the scheme of things to implement.

Overall, the health care financing approaches in India have remained lopsided focusing on demand side interventions and high dependence on the private sector for both inpatient and outpatient illnesses. The key policy dilemmas are: (a) how healthcare financing mechanisms can address the issue of supply side, (b) what institutional and administrative mechanisms should be instituted to strengthen the private sector engagement and (c) what should be the healthcare financing mechanisms to address primary care challenge.

These policy dilemmas need to be addressed as our national health policy evolves.

The National Health Policy 2017: Through the Accountability Lens (Part 3)

III. Strategic Purchasing 

The NHP 2017 advocates for the strategic purchasing. Its effects can be significant as it  helps in aggregating the demand for health care, unbundling and outsourcing some components within the health production process. Governments get in better position to restructure the supply-side of the market by responding to the needs of the population and strengthen developing mechanisms of greater integration of primary and hospital care.

However, it is not clear how the government will realize these benefits from strategic purchasing through existing Government financed health insurance schemes (GHISs).

The policy states that GHISs shall be aligned to cover selected benefit package of secondary and tertiary care services purchased from public, not-for-profit and the private sector in the same order of preference, subject to availability of quality services on time as per defined norms. 

This view does not reflect the fact that insurance companies already deal with a highly fragmented private health service providers and has its own problems in aggregating the demand.

There is general belief that some of the services such as diagnostic and various investigative procedures can be produced efficiently by the private sector and governments can buy these services and make them available to people in need. It is important to understand the context and characteristic of health markets in the background of policy option of strategic purchasing. One of the features on which the markets are typified is whether they are contestable. Contestable markets are one that has no exit/entry barriers. If in that market prices increase much beyond the average price level (and generate excess profits), potential rivals will enter the market to exploit this situation. The existing players will respond by bringing down the prices appropriate to yield normal profits. The perfect contestability will make it sure that even a single player can exhibit competitive behavior.

The way the medical markets have grown in India with no control on the need (domain and geographic specific), this market is not perfectly contestable as there are huge sunk costs creating huge barriers to exit and entry. It may be hard to find a suitable buyer of assets once it is discovered the entity is not doing well. 

Compounded with this is the fact that most decisions to use a particular procedure is decided by the doctor and not by the patients leading to a situation of information asymmetry between doctors and patients. Given perverse incentives, this leads to a situation of supplier-induced demand. With these imperfections, it is well known that insurers are not in position to address this problem. For example, the fee for service system, which increases the discretion and unnecessary clinical interventions, adversely affects insurance. In private health care settings, in particular, the ability to pay takes precedence over the need, and pricing policies give dominance to business interests over health care. The recent cardiovascular stents pricing illustrate this point leading to strong regulations.

Some countries have made reforms towards improving the contestability in the health markets by separating the role of purchaser and provider. This is done through formalizing relationships between buyers and sellers in the form of contracts, which articulate the volume, price and quality characteristics of transactions aimed at improving contestability in health markets*. This is the reform UK embarked on through the creation of quasi-markets when District Health Authorities were assigned the role to assess local health care needs and purchase "cost-effective" treatments to meet these needs within available budget**.

NHP 2017 proposes to step in areas of strategic purchasing without examining the contours of reforms critical for its successful implementation. 

The pace and consequences with which the process of strategic purchasing unfolds in the system are always unpredictable. There are several reasons for optimism for these strategies, but at the same time, some well known grounds for caution need to be addressed.

How does one instill accountability and responsibility of clinicians recommending the purchase of services without having sound budget culture? In a large system clear identification of roles and rules is a challenge and on top of it ensuring (a) what is being purchased, (b) for whom it is purchased and (c) of what quality requires sophisticated responsibility/accountability systems in place. How does the system protect from market price manipulations and inflation in costs? Just stating that multi-stakeholder trusts or registered societies with institutional autonomy will be created is an over simplification of the strategic purchasing challenge.

The policy makes a suggestion for creating a robust independent mechanism to ensure adherence to standard treatment protocols. The mandatory disclosure of treatment in a transparent manner and compliance to right of patients to access information should be an integral part of the system reform. But they should not be seen just in the context of strategic purchasing only.

Given we have limited knowledge of cost-effectiveness of various technologies available, the problems of measurability and contestability associated with expensive, complex and concentrated procedures may require a stronger regulatory environment and skilled contracting mechanisms before governments can rely on obtaining these services from the private sector*. 

The accountability framework for strategic purchasing strategy needs to evolve.

* Alexander S. Preker, April Harding, and Phyllida Travis (2000) ‘‘Make or buy’’ decisions in the production of health care goods and services: new insights from institutional economics and organizational theory. Bulletin of the World Health Organization, 2000, 78 (6) 779-790.

** Alan Maynard (1991) Developing the Health Care Market. The Economic Journal, 101:1277-1286.

The National Health Policy 2017: Through the Accountability Lens (Part 2)

II. National Health Insurance Scheme (NHIS)

One finds it perplexing that there is no discussion on national health insurance scheme (NHIS) of the Government of India in the NHP 2017.  The 28-page NHP 2017 document makes one passing reference to NHIS in context of covering selected benefits through strategic purchasing by the government.

Various state governments during the last decade have responded to OOP expenditure on health challenge by implementing demand side financing options. For example, the implementation of targeted health insurance options such as RSBY and RSBY+ by pooling the risks and providing protection from catastrophic expenditures started by the Ministry of Labour and later shifted to Ministry of Health and Family Welfare has been one major health financing reform.

As per the IRDA annual report of 2015-16, about 273 million persons are covered through various government-sponsored health insurance schemes currently in India. The annual spending by government, having contributions from both centre and state, on these schemes is about Rs 2,500 crore per annum of which the central assistance is to the tune of Rs 1500 crore. 

The announcement of new health protection scheme by the Finance Minster during 2016-17 budget speech also proposed an incremental health reform for RSBY by promising to increase the health cover to Rs 1 lakh from Rs 30,000 per family per annum. An additional top-up package of Rs 30,000 for senior citizens was also approved and implemented with effect from 1 April 2016.

The implementation of NHIS has been projected an important foundation for the national framework for the universal health care (UHC).

The situational analysis report presented as part of NHP 2017 identifies a number of challenges with NHIS. However, The NHP 2017 does not give any indication how the government would like to take this important demand side intervention forward and how are they going to address various challenges in implementing this insurance scheme.

One was expecting some discussion and deliberation on the NHIS. For example as can be seen from figures presented below, that in 12 states the targets of family coverage are below 60 percent and in significantly a large number of states the utilization of the scheme remains at very low levels (source RSBY Programme website http://www.rsby.gov.in/Statewise.aspx?state=16 accessed on 20 March 2017).

We have lost an opportunity to discuss an important issue on the role of insurance in national health protection and inclusiveness of population coverage (targeted to universal).

Among other things issues such as inclusiveness and comprehensiveness of benefits and coverage including integration with primary care were critical at this juncture of making health protection strategy effective. 

The policy could have laid the foundation for articulating strategies to strengthen the NHIS focusing on the 

• administration and institutional framework to ensure standards for service providers, 
• incentives for efficiency in the use of medical resources, 
• reimbursement of providers, and 
• delivery and resources. 

All these have a significant bearing on the impact on the efficiency of resource use. The policy has missed an opportunity to reflect on the national health protection programmes and pathways of balance the system of reforms on (a) population coverage (who benefits and basis of subsidizing their needs), (b) programme benefits (and incentives for efficiency in the use of medical resources) and (c) financing (equity issues in financing) with implementation feasibility. 

None of these find a reference in NHP 2017.

The National Health Policy 2017: Through the Accountability Lens (Part 1)

Background

The health policy broadly defines the key strategies of the government contouring its role and the proposition of engagement with the principal stakeholders towards achieving health goals. There are two reasons why the government’s role is pivotal in the health sector. One is because of severe market failure, which among other things include problems of imperfect and asymmetric information, and failure of markets because of significant externalities. The health policy must ensure that government strategies are aimed at correcting or compensating for these failures. Second is the doctrine of beneficence suggesting moral obligation of the government to act for the benefit of its citizens, often by preventing or removing possible harms. Within the backdrop of SDGs, the NHP 2017 approved by the Government recently sets its goal as:

Attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence. This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.

I. Collectivists View of Health Financing and Delivery

Nearly seven decades ago in 1946 Bhore Committee had put forth the collectivist view arguing that health services would be available to all citizens, irrespective of their ability to pay. This view was construed at a time when globally there was the belief that willingness to pay and ability to pay can guide the allocation of health care resources in any country and the development of the strategies can be designed based on these two principles. A few decades later this collectivist view was rearticulated in Thatcherism era in the UK in the eighties as follows:

Adequate health care should be provided for all, regardless of their ability to pay, must be the foundation of any arrangement for financing the health services.

The NHP 2017 reiterates this view of the provision of universal access to good quality health care services without anyone having to face financial hardship as a consequence. The NHP 2017 echo’s the Bhore Committee view, which among other things had suggested that:

There should be provision for every patient, if his condition requires it, to secure the consultant, laboratory and other special services, which may be necessary for diagnosis and treatment. There should also be provision for the periodical medical examination of every person, sick or healthy, so as to ensure that his physical condition is appraised from time to time and that suitable advice and medical aid, wherever necessary, are given in order to enable him to maintain his health at the highest possible level.

The Committee at that time had laid down the basic foundation for the health delivery system in India suggesting that the most satisfactory method of solving this problem would be to provide a whole-time salaried service which will enable governments to ensure that doctors will be made available where their services are needed. Based on this strategy and following Alma Ata declaration India developed and implemented a comprehensive structure of primary, secondary and territory care system to ensure health for all. However, due to health transition and various emerging challenges, the performance of health system particularly in recent times has not met the expectations. India could not achieve all the MDGs. Today the health system is not in shape to address the NCDs, which now account for 60% of country’s illness burden. We are deficient on most critical health system parameters.

The significant reliance on the private sector has resulted in high OOP expenditures on health, and over 63 million persons are pushed into poverty every year due to this. The policy recognizes that public health delivery system is not responsive and fails to provide healthcare to all. The consequences of OPP expenditures on health care are serious affecting lives of a large section of the population. These and other challenges arose because of the public health sector, which assumed responsibility for producing and distributing the services, and it was not able to cope up with the demand or also turned out to be inefficient. The collectivist promise of previous policies, starting from Bhore and then in 1983 and last health policy of 2002 could not be delivered. The fact remains that the health system is not able to cover the entire spectrum of health care needs.

To meet these challenges, the NHP 2017 puts the fulcrum on the public health system in following words:

Reinforcing trust in public health care system by making it predictable, efficient, patient centric, affordable and effective with comprehensive package of services and products that meet immediate health care needs of most people.

Towards this the policy has set a target of increasing utilization of public health facilities by 50% from the current levels by 2025. However, the key strategy and the details of institutional reforms as a step towards the government plans to strengthen the public systems remain to be seen. The NHP 2017 falls short on this dimension of outlining the process of reforms except stating that the strategy of having periodic measurement and certification of the level of quality as a strategy to reform the public systems. One doubts whether these measures outlined in policy are going to deliver the results without considering and attending to the institutional, structural and incentive reforms and examining the responsibility structure in the health system. During this transition, the policy states that there would be many challenges and as an intermediate step the policy suggests:

Purchasing care after due diligence from non-Government hospitals as a short-term strategy till public systems are strengthened.

It remains to be discerned how states are going to participate in the reform process and initiating change process to strengthen and create trust in pubic facilities as most of them are within the state level jurisdictions.

New National Health Policy of 2017

The Government of India finally approved the new National Health Policy (NHP) 2017. Through this blog I am providing a brief synopsis of this policy.

Objective of the Policy

The main objective of the NHP 2017 is to achieve the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence. 

The policy puts appropriate emphasis on prevention and promotion of good health. The NHP advocates allocating major proportion (two-thirds or more) of resources to primary care followed by secondary and tertiary care. I welcome this statement part as focus on primary care is critical to reducing future burden in the society. However, we need to have strong monitoring systems that health budgets are allocated keeping the focus on prevention.

The policy informs and prioritizes the role of the Government in shaping health systems on the following dimensions:

• investment in health (commitment to increase government health spending to 2.5% of GDP in time bound manner)

• organization and financing of healthcare services

• prevention of diseases and promotion of good health through cross-sectoral action

• access to technologies

• developing human resources

• encouraging medical pluralism

• building the knowledge base required for better health, financial protection strategies and 

• regulation and progressive assurance for health

The roadmap of the NHP 2017 is predicated on public spending and provisioning of a public healthcare system that is comprehensive, integrated and accessible to all. The Policy seeks to reach everyone in a comprehensive, integrated way to move towards wellness.  It aims at achieving universal health coverage and delivering quality health care services to all at an affordable cost.

The policy also looks at reforms in the existing regulatory systems both for easing manufacturing of drugs and devices, to promote Make in India, as also for reforming medical education.

The policy seeks to ensure improved access and affordability of quality secondary and tertiary care services through a combination of:

• public hospitals and strategic purchasing in healthcare deficit areas from accredited non-governmental healthcare providers, 

• achieve a significant reduction in out of pocket expenditure due to healthcare costs, 

• reinforce trust in the public healthcare system and 

• influence operation and growth of private healthcare industry as well as medical technologies in alignment with public health goals

The policy emphasizes reorienting and strengthening the Public Health Institutions across the country, so as to provide universal access to free drugs, diagnostics, and other essential healthcare. While the policy seeks to reorient and strengthen the public health systems, it suggests examining afresh at strategic purchasing from the private sector and leveraging their strengths to achieve national health goals. The policy looks forward to have a stronger partnership with the private sector.

The NHP, 2017 advocates a positive and proactive engagement with the private sector for critical gap filling towards achieving national goals.  It envisages private sector collaboration for strategic purchasing, capacity building, skill development programmes, awareness generation, developing sustainable networks for the community to strengthen mental health services, and disaster management. The policy also advocates financial and non-incentives for encouraging the private sector participation.

It also advocates extensive deployment of digital tools for improving the efficiency and outcome of the health care system and proposes the establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the continuum of care.

CSR Spending on Health: The Promise of Altruism

India's Companies Act 2013 mandates companies to spend about 2 percent of their profits on CSR. Crisil in their CSR Yearbook finds that 1505 companies were meeting conditions to have mandatory CSR spending requirement in fiscal 2016. Of these companies, 77% have reported their CSR spending. 

Overall the CSR spending has increased from Rs 6,841 crores to Rs 8,349 crores from 2015 to 2016 fiscal, showing an increase of 22 percent. The spending on health and sanitation has shown an impressive increase of Rs 739 crores (39 percent increase over last year) and the total CSR spending on health and sanitation is Rs 2,614 crores. The share of Health in CSR spending is about 31 percent. 

Most of these spendings have been routed through various NGOs.

 CSR Spending on Health 2016 (Rs Crores and %)

Source: Altruism Rising: The CRISIL CSR Yearbook, January 2017

Increase in CSR Spending Sector-wise in 2016 (Rs Crores)

Source: Altruism Rising: The CRISIL CSR Yearbook, January 2017

Of course, there is significant challenge of CSR spending on health. The cost-effectiveness of interventions needs to make an integral part of these investments. The CSR spending can not substitute state action, and in health, the collaboration with government will bring the scale make interventions cost-effective. Achieving health goals need a lot of behavioral changes at various levels, and these interventions are implemented through civil society. Ensuring that these interventions are effective will need flexible funding. Complimenting and collaboration are the routes to create maximum impact. 

Source: Altruism Rising: The CRISIL CSR Yearbook, January 2017