In her 10-point agenda for the vision for the decade, new finance minister Nirmala Sitharaman spoke about the importance of a “healthy society”, and specifically “Ayushman Bharat, well-nourished women and children and safety of citizens” as critical to meeting the goal.
It was thus a surprise that the budget speech had no mention of Ayushman Bharat or other recent initiatives for health by the Union government.
A closer look at the budget numbers, however, is not disappointing. The Union government’s budget allocation for the ministry of health and family welfare (MoHFW) increased by Rs 1,260 crore (or 2%) compared to the interim budget. Upon a comparison with last years revised allocations, this represents a Rs 8,514 crore (or 15%) increase. This is a significant and much-needed step, especially given that the Economic Surveys served as a reminder that India remains below its goal of 2.5% of GDP on health by 2025.
The interim budget allocations
A few months ago at the interim budget stage, the focus of the budget was on the twin initiatives under the governments flagship Ayushman Bharat. The scheme has two components: the Pradhan Mantri Jan Arogya Yojana (PMJAY) – a health insurance scheme aimed at providing access to quality inpatient secondary and tertiary care to poor and vulnerable families and reducing out-of-pocket expenditures arising out of catastrophic health episodes for 10.74 crore families – and, the upgradation of 1.5 lakh sub-centres and primary health centres to health and wellness centres (HWCs) by providing a continuum of quality care by 2022.
The result had been a significant increase in allocations for both. While allocations for PMJAY had increased 2.5 times compared to the revised estimates in 2018-19, those for HWCs have seen a 33% increase.
The worry was that the substantial increase in PMJAY investments was at the cost of primary health care.
Over the years, the allocations for Reproductive and Child Health (RCH) had seen a declining trend – falling 24% between 2017-18 and 2018-19 (revised estimates) and further by 8% in the interim budget.
Allocations for NHM increase
This year, no change has been made to allocations for Ayushman Bharat. Compared to most of the other social sector schemes including for education and nutrition, the NHM budget increased by 4% from the interim budget. This represents an 8% increase or Rs 1,062 crore from the revised estimates of 2018-19.
While still not the same as their 2017-18 levels, in the full budget for 2019-20, allocations for RCH, too, seem to have made a partial recovery, with Rs 450 crore additional allocations compared to the interim budget.
The focus of the health budget seems to have prioritised Health System Strengthening under NHM – which represent investments in ensuring that public health facilities meet Indian Public Health Standards (IPHS) and provide quality care.
This is in line with the government’s endeavour of improving health infrastructure. Moreover, even Community Health Centres (CHCs) are a critical component to PMJAY, as all CHCs and public hospitals are deemed empanelled.
According to the fourth round of the National Family Health Survey (NFHS-4), 52% people in the bottom two wealth quintiles generally did not use a public health facility mostly due to perceived poor quality of care, a lack of nearby facilities, and long waiting times.
The increasing investments in Health System Strengthening are reflected in the increase in new constructions and upgradations. According to a response to a question in the Parliament, between March 2014 and March 2018, there was a 27% increase in new construction works and a 40% increase in renovation or upgradation works under NHM.
The need to invest and improve infrastructure is evident from a look at the large number of vacancies and poor quality of health infrastructure. In March 2018, only 7% SCs, 12% PHCs and 13% of CHCs were functioning as per the Indian Public Health Service (IPHS) – which set requirements in terms of personnel, the availability of facilities, and services provided.
There was no CHC functioning as per these norms in 19 states out of 33 for which data was available, including Andhra Pradesh, Assam, Jharkhand, Karnataka, and Rajasthan. Gaps in infrastructure apart, human resources were health, particularly of specialists such as (surgeons, OB-GYNs, physicians, and paediatricians) were limited.
As per the Rural Health Statistics, available till March 2018, only 61% of all required posts for specialists at CHCs have been sanctioned and of those sanctioned, over 70% of the posts are lying vacant as on March 2018.
The budget has taken a few steps in the right direction, but there is a need to intensify public expenditure on health. Increased spending on health system strengthening does aim to address gaps in quality, but the government needs to pay more attention to convergence across ministries such as the ministry of women and child development and MoHFW.
A recent paper by Menon et al (2019) on the National Nutrition Mission showed that few beneficiaries receive the complete set of services that they should. This requires improved coordination between MoHFW, MWCD, MJS (Ministry of Jal Shakti), among others.
If the aim is to transform India into a ‘healthy society’, then surely we require significantly more than this budget offers.
Avani Kapur and Ritwik Shukla are with the Accountability Initiative at the Centre for Policy Research.