What the health sector needs is much greater attention – in terms of both financial and human resources – if it is to meet the demands of providing universal and free healthcare.
In the run up to this year’s budget, many anticipated major announcements related to the social sector, including health. It was expected that in the context of demonetisation and five states going to the polls soon, this budget would be ‘pro-poor’. The health minister demanded higher allocations for his department and it was also reported that the Niti Ayog had recommended a three-fold increase in the health and education budgets. The Union Budget 2017 is disappointing as far as the health sector is concerned. The already underfunded sector has not seen much of a rise this year either.
There is an overall increase of almost 24% in the health budget from the revised estimate (RE) of 2016-17 – Rs. 38343 crores to Rs. 47352 (16% in real terms). The major increase has come for components of the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) (Rs. 2021 crores) and measures to strengthen the health system under the National Rural Health Mission (Rs. 2820 crores). While this might seem like a significant rise, the budgetary allocations for health are still highly inadequate and will continue to keep India amongst the world’s lowest spenders on health. Including state governments’ spending on health, public expenditure on health in the country is only about 1.3% – amongst the lowest in the world.
The 12th plan as well as the high level expert group report on universal health coverage aimed to increase health expenditure to 2.5-3% of the GDP. To achieve this, the central government’s contribution would also have to at least double as a proportion of GDP. As of now, the central government’s allocations for health remain around 0.3% in both 2016-17 (RE) and 2017-18’s Budget estimate(BE). Therefore, in terms of what is required and where India stands on public health spending, the increase in the health budget is nominal.
While the various health goals listed by finance minister Arun Jaitley are indeed laudable, this Budget betrays a complete lack of vision when it comes to actually moving towards these outcomes and ensuring health for all. There are some piecemeal measures that have been announced such as converting sub-centres to health and wellness centres, creating two new AIIMS, creating additional postgraduate seats in medical colleges, promoting the use of generic drugs and Aadhar-based smart cards for senior citizens.
For instance, while there is a proposal to start two new AIIMS in Jharkhand and Gujarat (presumably where the additional budget to PMSSY will go); what about infrastructure and human resources for the AIIMS hospitals that have been set up in the last few years. There have been protests by medical students in AIIMS Bhopal, Jodhpur and Patna regarding the lack of infrastructure for patients, poor academic facilities and shortage of faculty which need to be addressed urgently if these institutes are to train quality doctors and provide high quality treatment.
Similarly, when it comes to health sub-centres – according to the ‘Rural Health Statistics 2016’ report brought out by the Ministry of Health and Family Welfare, less than 14% of the 1.5 lakh health sub-centres in the country meet the IPHS (Indian Public Health Standards) norms. Additional resources are required to ensure that health facilities from the sub-centre level to the tertiary hospitals are well-equipped in infrastructure, drugs and diagnostics; and human resources. Instead of focusing on these basic aspects of providing health care, the budget tries to come up with fancy new ideas such as setting up “health and wellness centres”; which might only be something cosmetic.
What India’s health sector needs
The health sector in India has been lacking a comprehensive vision and backing by resources; and this has extended to all aspects of health provision including prevention, promotion and treatment. While there was a general consensus on the need to strengthen health systems and move away from vertical programmes that are disease-centric; health policy in India has been pursuing two different tracks in parallel. On the one hand is the National (Rural) Health Mission (NHM) which aimed at strengthening the public health system, especially at primary levels, in a decentralised and participatory manner and on the other the Rashtriya Swasthya Bima Yojana (RSBY), which is basically a publicly funded, targeted health insurance scheme providing cashless inpatient services in private or public hospitals (for up to Rs 30,000).
In the last Budget (2016), it seemed as if this government’s approach was to take the insurance route to universal health coverage. A national health protection scheme (NHPS) was introduced by the same finance minister with great passion last year. This was basically a revamped RSBY with expanded coverage, providing health cover of up to Rs 1 lakh per family. Only Rs 1500 crore was allocated for NHPS last year and the allocation this year is even lower at Rs 1000 crore. While health insurance is not the desirable option, the fact that after all this hype (it was also mentioned in the prime minister’s Independence Day speech), this scheme hasn’t even taken off yet raises serious doubts about the credibility of the government’s announcements.
Just as expanded health insurance became the headline initiative in the social sector last year, this year it is the provision of Aadhar-based smart cards containing the health details of senior citizens. Much has been written about the failure of Aadhar-based authentication – especially for the elderly – and it would be dangerous and exclusionary if these cards were now made mandatory for the elderly to access healthcare.
What the health sector needs is much greater attention – in terms of both financial and human resources, as well as stewardship towards strengthening the public health system – to meet the demands of providing universal and free healthcare. Careful thought needs to be given to how the private sector, which is currently dominant in size, must be regulated. Social determinants including nutrition, water and sanitation, education et cetera also need to be addressed for the government to have any impact on health outcomes. Unfortunately, all we have is a lack of vision and some ad hoc and disparate measures.
Dipa Sinha teaches at School of Liberal Studies, Ambedkar University, Delhi.