The experience of the COVID-19 pandemic in the last few years has forced a painful exposition of the many lacunae within our public health systems in terms of infrastructure and human resource. We have also learned that in spite of these lacunae, they have remained the mainstay for the vast majority of Indians unable to pay the costs of care in the private sector.Considering this, it seems an act of utter forgetfulness to find that the budget for 2023-24 has given the sector of health such short shrift.Expenditure on health. Visualisation: Jahnavi Sen/The WireOstensibly, the budget for the Ministry of Health and Family Welfare, combined with the Ministry of Ayush, has increased by Rs 3,552 crores – to Rs 92,803 crores – when compared to the Budget Estimate of 2022-23. However, if adjustments are made for inflation, this reflects a decrease of 2% in real terms. When it comes to the core central programmes related to health, the National Health Mission sees an actual decrease from Rs 37,160 crores (BE of 2022-23) to Rs 36,785 crores (BE 2023-24). Counting for inflation, this gap would be even higher – Rs 1,438 crores, in real terms.The component of Ayushman Bharat that pertains to the strengthening of sub-centres and primary health centres of the public health systems has been combined with other components into the PM Ayushman Bharat Health Infrastructure Mission which receives Rs 4,200 crores. This, compared with Rs 4,177 crores budgeted in 2022 appears to be another decrease in real terms.Simultaneous to this fairly explicit lack of support to the public health systems to expand infrastructure and public health programmatic capacities, the one area that has seen an increase is the insurance scheme of PM Jan Arogya Yojana, from Rs 6,457 crores (BE of 2022-23) to Rs 7,200 crores (BE of 2023-24).There are at least two major implications of these trends. The first pertains to the issue of the ‘last mile’ delivery of all health programmes to communities, especially preventative, promotive, palliative and rehabilitative services, as well as critical aspects of medical management pertaining to early diagnosis, basic treatment, timely referral and continuity of care for chronic diseases.Also read: Eight Charts to Explain the State of Rural Healthcare in IndiaAll these depend almost entirely upon the community health worker, or those who execute the ASHA programme, currently comprising about 10 lakh ASHA workers, mostly in rural areas. This programme was considered a transformative element of the National Rural Health Mission when it was launched in 2005 and has been lauded for its vision and, to some extent for its contribution to health outcomes related to women and children despite many challenges and lack of much-needed support. The NHM not only retains this element but also seeks to expand it, in principle, to urban areas. Considering that institutional medical services really lie at the tip of the iceberg of public health action for communities, it has long been argued by public health professionals that ASHA workers be formalised as health workers and be given decent remuneration, training and career opportunities for growth. However, given that the NHM budget has only declined, it is only too clear that there is no intent for either expansion or formalisation of the ASHA programme.The Anganwadi workers of the Integrated Child Development Services form another women-only fleet in this nearly 50-year-old programme and also fulfil important public health functions with respect to children under the ages of six, along with pregnant and lactating women. Here too, the same story applies: the Saksham Anganwadi programme comprising two other schemes besides the ICDS has been given a budget of Rs 20,554 crores as compared to Rs 20,263 crores (BE of 2022-23) last year reflecting a decrease in real terms. Every single stated goal and objective that the country has set itself with respect to public health ultimately depends upon these frontline workers as the link between the health system and the community. Considering there is so much talk of unemployment, partial employment and women’s low participation in the workforce, this missed opportunity to formally acknowledge the labour of 40 lakh women and their critical contribution – real and potential, for public health work is inexplicable and paradoxical.The next tier of services are clearly the sub-centre and the primary healthcare centres which are to be transformed into ‘Health and Wellness Centres’ with additional focus on non-communicable diseases and an additional worker; the Community Health Officer. The previous budget had allocated funds for the creation of 150,000 HWCs throughout the country and currently 156,586 are said to exist. However, if all existing sub-centres and primary healthcare centres are to receive equivalent treatment, this figure of such centres would need to go up to 188,398 and the budget would need to increase by 20%. As mentioned above, the current budget seems not to accommodate this either.With the current level of interest, close-to-ground health services can remain stagnant at best. Here, the investment into health insurance assumes a particular significance as a tacit means to herd patients to access private medical services of the curative variety, without establishing adequate systems for either disease prevention or management through the public health systems. While an analysis of the Pradhan Mantri Jan Arogya Yojana is beyond the scope of this article, there is much evidence to alert us to the consequences. About 75% of the PMJAY expenditure lies in the private sector, which sees about 60% of all claims. It is seen that out-of-pocket expenditure has not, in fact, reduced as a result of insurance. Thus money from the public exchequer is routed to private health systems without achieving the main objective of enhanced access to health care without out-of-pocket expenditure. Ironically, the private sector has also been reluctant to enter into partnerships with the government, claiming insufficient financial packages. The current increase for PMJAY, but also additional resources for the Central Government Health Scheme, from Rs 1,850 crores in 2022-23 to Rs 2,220 crores in 2023-24, and medical expenses of pensioners from Rs 2,645 crores in 2022-23 to allocation of Rs 3,846.19 crores in 2023-24, will certainly offer private players greater incentive.Budgets reveal the vision and intent of governments. Strengthening the public health systems of the country and expanding them to cover the population universally, especially the urban poor, seems not to be a priority. Attendant are the issues of transfer of public funds to a poorly regulated private health sector, and the continuing discrimination against an enormous female workforce that labours at the very heart of public health action in communities that need it most.Dr Vandana Prasad is a community paediatrician and public health professional associated with the Public Health Resource Network.Edited by Soumashree Sarkar.