The funding for the National Health Mission (NHM), the expanded form of the flagship programme of NRHM initiated in 2004 to strengthen the public health services, has been dropping consistently over the years.
In the financial year 2016-17, the government of India allocated Rs 19,437 crore for the NHM. This was a 2% increase over the 2015-16 allocations, but a dismal 1.18 % of the GDP expenditure. The 2019-20 interim budget has raised the allocation for the NHM from Rs 30,683 crore in 2018-19 to Rs 31,745 crore. This is close to the actual spending on NHM during 2017-18, which was Rs 31,510 crore.
In the past, during the meetings of the Mission Steering Group (MSG) of the NHM, we, as then members, consistently raised our concern regarding the mission’s underfunding. We are still grappling with the fact that public facilities in most parts of the country fall far short of the need and do not provide free access to medicines and diagnostics.
There is a visible failure in addressing the critical issues around strengthening the health system, such as access to generic medicines and diagnostics, freeze on recruitments in health sector, and contractualisation of health workforce. There is a huge deficit of human resources, which rises to over 80% in the case of specialists. Allocations for reproductive and child health (RCH) have been falling steadily from 40% to 15%. Maternal and child health, malnutrition, etc., have not received any priority either. Similarly, the funding for communicable diseases fell by 27%.
Ayushmaan Bharat envisages expansion of primary healthcare by upgrading the sub-centres to health and wellness centres (HWC). However, a significant proportion of sub-centres currently are reported to have poor infrastructure, are heavily understaffed and do not have the equipment or the drugs required for their functioning. For a sub-centre to be successfully upgraded to a HWC, it is important to allocate more funds.
Though the allocation for the NHM for 2019-20 has been raised, it is only an increase of Rs 1,062 crore over the 2018-19 budget, which does not even cover the prevailing inflation rate. The amount set aside for HWCs for 2019-20 is Rs 1,350 crore. Because HWCs are a new intervention, allocations should be in addition to expenditure on the existing NHM interventions. Here, it is obvious that the increased allocation to HWCs would have to come at the expense of other interventions, which is is extremely problematic.
In contrast, in this interim budget, the public funded Ayushmaan Bharat health insurance scheme (PMJAY) has received a major hike from Rs 2,000 crores to Rs 6,400 crores, even though it only covers selective in-patient care. Outpatient care, which accounts for the bulk of healthcare expenditure that people spend, is completely ignored by the PMJAY. The advocates of this scheme say outpatient care is not amenable to insurance mechanisms. This is a clear and deliberate intention to gradually weaken the public health system and move towards an insurance-based model of healthcare. However, such a move at the expense of the public health system will lead to disastrous results for a country like India, where a large section of population is poor and is critically dependent on public provisioning of healthcare.
The need of the hour is to revert attention to the NHM, which emphasised strengthening the public health systems for providing comprehensive care. There is also a requirement for higher levels of investment and human resources in this endeavour, not just a targeted package of curative services that the PMJAY aims to provide.
Sarojini Nadimpally, Yogesh Jain and Amar Jesani are ex-members of Mission Steering Group of the National Health Mission.