New Delhi: The Economic Survey 2022-23 highlights several achievements of India during 2022-23. The Covid-19 vaccination drive which led to the inoculation of more than 90% of the country’s population was laudatory. The consistent decline in maternal and child mortality indicators also deserves to be celebrated. However, certain claims made in the Survey did not reveal the full story.
In five points, we explain what those are:
1. Rural healthcare: Buildings and human resource
The survey lauds the rise in the number of health sub-centres (SCs), primary health centres (PHCs) and community health centres (CHCs), along with “the rise in doctors, nurses, and other medical personnel over time”. While the total number of these health facilities has gone up over time, the recently released Rural Health Statistics (RHS) 2021-22 clearly showed that lack of human resources was ailing them – and thus affecting access to healthcare for the majority of citizens residing in rural areas. Every CHC, according to the government’s own norms, ought to have at least one surgeon, obstetrician/gynaecologist, anaesthetist, and paediatrician.
One of the most telling features of the RHS was the fact that in many states, hundreds of CHS didn’t have even one specialist. The very purpose of CHCs – to position specialists in rural areas – is defeated. The shortfall of nurses in some states’ CHCs along with PHCs, which occupy the mid-tier in rural healthcare, continued to rise. And, on the other hand, auxiliary nurse midwives (ANMs), which are key to managing SCs – the lowest facility in the system – are also short in number in various states. The RHS highlighted various other gaps not just in human resources but also infrastructure – all of which find no mention in the Economic Survey.
The Survey also says that the doctor-population ratio is now 1:834 – which is below the WHO norm of 1:1000. But while calculating this, the Survey makes an important assumption that out of 13,08,009 registered ‘allopathic doctors’ and 5.7 lakh ‘Ayush doctors’, at least 80% would remain available for patients, or remain present. While no rationale has been shared for making this assumption, the Economic Survey of 2018-19 had raised a concern. Talking about PHCs which exist with ‘one doctor or without a doctor’, it had said thus:
“Moreover, what this data does not reveal is that even if the personnel are present, their level of participation in providing health services, may not be at desirable levels due to lack of supplies, inadequate infrastructure facilities, poor monitoring of the staff, and so on. Public health services delivery in rural areas warrants better governance mechanisms through adoption of technologies, community and Local Self Government (LSG) participation and social audit.”
No Economic Survey or any government document after this followed up on this observation, made four years ago. This year’s survey is also silent on this while talking about ‘improved recruitment of doctors and supporting staff’.
2. NFHS-5: Survey says and survey hides
The Economic Survey 2022-23 drew upon various findings of the National Family Health Survey (NFHS)-5, like the decline in total fertility rate, increase in institutional delivery rates, maternal and child mortality indicators and increase in the number of households covered under any insurance or financial scheme. While NFHS-5 indeed points to these hits, it indicated a few important misses as well. One of them was questioning the status, if not in letter, in spirit, of the status of declaring the country ‘Open Defecation Free’ (ODF). The NFHS-5 said: “Nineteen percent of households do not use any toilet facility, meaning that they practise open defecation.” In rural areas, the proportion of inaccessible toilets was much higher than the country’s average.
Despite this revelation, the Economic Survey 2022-23 goes on to reiterate that India has become ODF. “Having achieved the ODF status in all villages in the country as of 2 October 2019, Phase-II of Swachh Bharat Mission (Gramin) is now being implemented during FY21 to FY25, with the focus to sustain the ODF status of villages and covering all the villages with Solid and Liquid Waste Management…”
The NFHS also pointed out that stunting and wasting in children – two important indicators of malnutrition – had declined, though the decline was unlikely to meet the deadline for the UN’s Sustainable Development Goals (SDGs). The Economic Survey also alludes to NFHS-5 to show this decline. But an alarming revelation of NFHS-5, that anaemia increased by eight percentage points, is not discussed in the Survey.
3. Health expenditure: Out-of-pocked spend declined?
The Economic Survey 2022-23 claimed that out-of-pocket expenditure (OOPE) – money spent by people for healthcare services – has declined. India is known for an extremely high rate of OOPE – it accounts for more than 60% of the total health expenditure. The government’s claim of a reduced OOPE was a reiteration of what it had said in the National Health Accounts (NHA) 2018-19. That claim was contested even when NHA 2018-19 was released.
The consumer survey 2017-18, conducted by the National Statistical Office, formed the basis of NHA 2018-19 and also, 2017-18. Experts had argued that during the time of the survey, the very consumption of healthcare and other social services declined – i.e. people availed fewer services as compared to previous years. They said that it was unlikely that if there were no financial hardships, the utilisation of health services by people would go down.
But the government denied any allegations against the robustness of NHA methodology and dismissed the concerns as ‘selective picking of data’. One would have to wait for next year, when another round of consumer survey is conducted to see if the OOPE decline is indeed a trend – as the government indicates – or a mirage. The fact, however, remains that India is still far from spending even 2% of the GDP on health. In 2020-21, India spent only 1.6% while the target is to increase it to 2.5% by 2025, according to the National Health Policy.
4. COVID-19: Battle won?
The Economic Survey 2022-23 elaborates upon various efforts made by the government to create a three-tier infrastructure to treat COVID-19 patients. It claimed that the government has created critical care hospital units in all districts of the country and there is a public health lab network at the bloc level ‘to manage pandemics’.
“The timely intervention at all levels helped India navigate the Covid pandemic successfully despite successive shocks…India may have won a major battle. India is one of the countries which has learned the most from the pandemic to create a mechanism for protecting its citizens and economy,” the Survey said.
While declaring an apparent victory over the pandemic, the Survey did not refer to the sobering reality that India has the third-highest number of registered deaths worldwide due to the SARS-CoV-2 virus. But if one were to account for excess deaths – ones that official counts have missed, at least half a dozen of studies, including that of the World Health Organisation and the Institute of Health Metrics and Evaluation (published in The Lancet), said India has the highest number of such undercounting. The government did not accept these studies.
“After the successful rollout of two doses of indigenous vaccines, the third dose was introduced,” the Survey goes on to add. India indeed had one of the largest adult vaccination drives conducted, ever – even if the response to booster doses has been underwhelming. More importantly, there was no evidence that any of the scientific institutions of India were taken into confidence before announcing the formal rollout of booster doses.
While the worst phase of the pandemic may be behind India, and the rest of the world, any honest analysis of the country’s performance would go beyond what the Economic Survey 2022-23 describes – by also taking into account the devastation of life and livelihoods, and indeed the lessons learnt from mistakes.
5. Catch up exercise
The Economic Survey said in FY23, intensified childhood and maternal immunisation drives were launched to cover those children and pregnant women who missed their routine jabs due to obstructions caused by the COVID-19 pandemic. “Until December 2022, a total of 11 phases of Mission Indradhanush have been completed covering 701 districts across the country under which a total of 4.5 crore children and 1.1 crore pregnant women have been vaccinated,” it said. This was an important step undertaken by the government. However, there is no data in the public domain as to what the baseline is – how many children and expectant mothers missed their routine jabs. There are a number of international studies to say a variety of health services were impacted due to the pandemic but any long-term assessment from India is missing on this point. Services that were impacted include nutrition, cancer care, geriatric services, tuberculosis care, mental health, malaria elimination.