Just by looking at the numbers, the Budget for health seems promising. The total allocation for the department of health and family welfare (HFW) has increased by about 16%, which could be seen as a substantial hike considering there was hardly any year-on-year expansion during the previous term of this government. The total budget for the department for 2019-20 is Rs 62,659.12 crore, compared to the BE of Rs 52,800 last year. The budget for health is also not highly different from what was presented in the interim budget.
While many hoped otherwise, some issues that plague the health sector have still not received adequate attention.
In the recent electoral campaign, health was among the major issues raised by the ruling party, with the BJP projecting health both as an achievement (with the launch of Ayushman Bharat) and as a priority for future. Further, considering that the Budget comes at the heels of the death of more than 150 children due to the ongoing encephalitis crisis in Bihar, there was expected to be a greater focus on health.
These deaths were entirely preventable and highlighted the failures of the public health system and the urgent need to strengthen the delivery of healthcare, especially at the primary level. The importance of paying attention to nutrition and sanitation was also underscored.
However, the present government’s strategy for health continues to be more biased towards the Pradhan Mantri Jan Arogya Yojana (PMJAY), which basically provides insurance coverage for hospitalisation. The big increase within the health budget has been for PMJAY, from Rs 2,400 crores to Rs 6,400 crores. On the one hand, it has been pointed out earlier that this is probably not enough even to cover the Central government’s share towards premium charges for PMJAY, on the other, the inappropriateness of such a strategy for the health situation in India has also been widely written about.
Concerns have been raised about the limited potential of PMJAY towards reducing out-of-pocket expenditure. It is also feared that the scheme will divert resources away from strengthening public health systems and towards the private sector.
What one hoped for was greater allocations towards the National Health Mission (NHM) and other interventions that would strengthen the public healthcare system. The health and wellness centres (HWCs), which are part of the Ayushman Bharat package, continue to get very little support with the budget increasing only by around Rs 350 crores from the revised budget for 2018-19 (from Rs 999.96 crore to Rs 1,349.97 crores) for rural areas and by Rs 50 crores for urban areas.
According to a press release from the health ministry, only 8,030 HWCs were operational by February 4. Under Ayushman Bharat, the plan is to set up 1,50,000 such centres – while it is understandable that this cannot be achieved in one year, such a meagre increase in the budget allocation indicates a very slow pace in which this expansion is envisaged.
Such a modest increase is not even enough to double the number of HWCs from 8,000 to 16,000. HWCs are the main intervention to improve access to primary health care, the lack of which was so sadly felt during the Bihar epidemic.
Therefore, although there is an overall increase in the health budget, the required urgency that needs to be shown in the health sector is missing. If the government is to reach its budgetary objective of spending at least 2.5% of GDP on health by 2022 (according to the NHP 2017), then the rate at which the allocations are increased also needs to be accelerated.
Nutrition for women and children
A related issue is the allocations for the nutrition schemes for women and children. Health outcomes are closely linked to nutrition status and this is another area where the improvements in outcomes in India need to be better. Here again, what we see is a mixed bag – the allocation for the ‘Umbrella ICDS’ has gone up from RE of Rs 23,356.50 crore in 2018-19 to Rs 27,584.37 crore. Much of this increase is under the ‘anganwadi services’ (from Rs 17,890 crores to Rs 19,834.37 crores) and the National Nutrition Mission (from Rs 30,61.30 to Rs 34,00.00).
While once again, these are heads under which an increase in allocation was required, the amount is not enough. The increase in ‘anganwadi services’ will most likely be barely enough to cover the enhanced honorariums to anganwadi workers and helpers (which are still at very low levels) with not much available for improving the supplementary nutrition given to children or to improve the infrastructure in anganwadi centres, leave alone providing for additional workers.
Under the ‘Umbrella ICDS,’ two schemes which are critical both from the perspective of women’s rights as workers as well as improving childcare and nutrition – the Pradhan Mantri Matru Vandana Yojana (PMMVY) and the National Creche Scheme – continue to be neglected. The revised budget for 2018-19 for PMMVY was Rs 1,200 crore, a decline Rs 2,400 crore – which was the budget estimate, showing that the scheme has not taken off.
In 2019-20, once again the allocation is only Rs 2,500 crore, whereas a letter written to the finance minister last year by 60 economists recommended that the full-fledged implementation of this scheme requires Rs 8,000 crore in the Union Budget. The budget for the creche scheme has been reduced from Rs 128.39 crore to Rs 50 crore. So, although there are some overall increases, this Budget does very little for the most vulnerable populations such as women working in the informal sector or their young children.
It is time the government recognised that something drastic needs to be done for health and nutrition in the country, and these routine half-hearted efforts are just not enough.
Dipa Sinha teaches at Ambedkar University Delhi.