Two hundred and ninety children died at Uttar Pradesh's Gorakhpur's BRD Medical College in the month of August alone; meanwhile in Farrukhabad, also in UP, 49 children lost their lives around the same period. To say that public health expenditure in India is in disarray, especially in the aftermath of the tragedy in Gorakhpur would be an understatement.

At the national level, India spends a grand total of 4.7% of its GDP (according to 2014 figures) on health—which, when further sub-divided into categories points to government expenditure of a mere 1.4% and private expenditure standing at 3.3% according to a 2017 PricewaterhouseCoopers report. What this means is that not only does the private sector spend more than double its public counterpart, it also exerts a proportional degree of control over decisions taken in a sector where 60% of all spending is out of pocket expenditure (OOPE).

Most of the BIMARU states have not looked to utilise the additional funds for healthcare and have instead chosen to continue with the tradition of keeping healthcare expenditure at below 5% levels...

However what is more interesting is that after the Finance Commission's recommendations in 2015, to increase fiscal devolution, the onus has fallen onto states to determine what do with the 42% of Union taxes that they have access to. At the macro level, state expenditures on health as a percentage of GDP, when viewed longitudinally, have consistently remained lower than Central expenditure with the decision to devolve only leading to a marginal rise in spending which has now topped out at 0.9% in 2017.

What this has meant at the level of individual states can then only be seen in terms of state expenditure on healthcare and its translation into per capita expenditure on health. If one were to take the look at CBGA expenditure estimates in the case of Uttar Pradesh and contrast them with Kerala, one can very clearly see the two paths that states may adopt in terms of healthcare expenditure.

While Uttar Pradesh has spent 4.4% of its budget on healthcare, Kerala has chosen to spend 5.8%. On the ground this has translated into Uttar Pradesh having a per capita expenditure of an abysmal ₹670.5 on healthcare while in Kerala it translates into ₹1456 per capita.

While Indian finances have looked to devolve, the degree to which individual states have shouldered the responsibility to provide affordable healthcare has been varied, to say the least. The devolution of finances has had little to no effect in boosting total expenditure on healthcare. Most of the BIMARU states have not looked to utilise the additional funds for healthcare and have instead chosen to continue with the tradition of keeping healthcare expenditure at below 5% levels (with the exception of Rajasthan at 6%).

The said data then points to a very unequal future in the case of healthcare across the country. The first level of inequality operates at the national level with all those below poverty line simply unable to access healthcare due to the huge out of pocket expenditure required. To provide context, India's out of pocket expenditure on health care stands at 62.4% (while the global average stands at 18%) with our Chinese neighbours having nearly half that figure at 32%.

The recent tragedies must then be seen not as isolated incidents but as by-products of sustained apathy by successive state governments in the healthcare sector.

At the level of states however, this has come to mean that people in BIMARU states are much more likely to have inadequate healthcare than other states in the country and this may continue to be the case for the foreseeable future as state governments refuse to increase spending on the sector even though they consistently feature in the bottom five on indicators such as infant mortality rate (IMR), maternal mortality rate (MMR) and under-five mortality rate.

Uttar Pradesh, specifically, has consistently been a terrible performer on health indices and is currently the worst state in the country in terms of its IMR (65) and under- five mortality rate (78), while also historically being one of the lowest spenders per capita on health. The recent tragedies must then be seen not as isolated incidents but as by-products of sustained apathy by successive state governments in the healthcare sector. The fact that the current government seems to have followed in the same footsteps of tackling symptoms, and not the root cause of inadequate state funds, only points to grave policy paralysis which may result in several more disastrous outcomes within the state in times to come.