Navneet Wadkar, Sayan Das
As COVID cases continue to rise and rise, and our health system gets overwhelmed, there’s a growing realization that without a robust public health system, controlling this pandemic will prove to be an uphill task. Kerala’s early success in controlling the epidemic, due mainly to its well-functioning public health system, stands out in contrast to the other Indian states. Even the government has woken up to these needs and promised increased Public Health spending, among other measures. The health component of the stimulus package under Atma Nirbhar Bharat Abhiyaan however has attracted criticism on several fronts, primarily because it re-purposes existing measures and fails to offer anything substantial or new, leading some to dub it a ‘Stimulus Package sans Stimulus’.
While much has been said about the current package, we fear this tendency is evident in the incumbent government’s earlier budgets too. Here we analyse health allocations in the last six budgets tabled by the National Democratic Alliance (NDA) government to show that the pandemic is not entirely to blame for the abysmal state of affairs today. It is years of gross neglect of the public health system that has pushed us to this brink.
The Current Health Budget
The 2020 union budget increased total allocations to healthcare by a meager 3.75% from previous year, much less than the 25% increment required annually to reach the National Health Policy 2017 target of 2.5% of GDP by 2025. India’s public expenditure on health (approx. 1.29% of GDP) remains one of the lowest in the world, lower than most other emerging economies and even some of its neighbors like Thailand (2.8%) or Sri Lanka (1.6%). This dismal state of health expenditure is not entirely unique to the current government. Like clockwork, successive governments have promised and subsequently failed to deliver. However, given the pandemic, a commitment from the government was much expected.
While total allocations in the current budget did not decrease, cuts were made in sectors that were already critical to the health system, and now in the context of the pandemic have assumed added significance. With an ever-increasing caseload and rising infection among healthcare workers, health sector human resources are already stretched thin, certainly not helped by the fact that the current budget had slashed funding to the ‘Development of Nursing Services’ head by almost 70%, and ‘Upgradation of Nursing Services’ by 100%. As per the World Health Organisation (WHO), India already suffers from a ‘critical shortage of healthcare providers’, and lacks 1.50 million doctors and 2.40 million nurses against WHO recommendations.
Twelve central government institutes, including AIIMS, Delhi, PGIMER, Chandigarh and NIMHANS, Bengaluru, collectively suffered a cut of Rs 555 crores in the current budget. The tertiary care public hospitals are at the center of our COVID management efforts; many have been designated explicitly for COVID treatment. Adhering to the strict infection prevention and control protocols are running hospital costs up manifold. The scuttling of funds would only hinder essential service delivery in this time of need.
Along with the state of healthcare, the question of immunity has also become central in this pandemic. Adequate and appropriate nutrition is vital for the optimal functioning of all cells, including the immune cells. During an infection, when the immune system is on the front foot, there’s an additional demand for energy where nutrition again plays a critical role. The importance of nutritional programs therefore cannot be overstated.
In the current budget, allocation of Rs 27,057 crore was made to the five major nutrition-related schemes of the Integrated Child Development Services (ICDS). The allocation is an increment of 3.7% compared to the previous year, but given past trends, far too inadequate for the requirements of the program. Other schemes that additionally influence nutritional outcomes, such as the Mid-Day Meal Scheme, National Health Mission, Food Subsidy Scheme, Mahatma Gandhi National Rural Employment Guarantee Scheme, National Rural Drinking Water Mission and others, inexplicably faced a collective budget cut of 19% compared to last year.
These steps make little sense in otherwise normal circumstances, and now the pandemic has clearly shown how counterproductive they have been.
Announced in the 2018-19 budget, Ayushman Bharat (AB) is the flagship health scheme of the NDA government with the twin programs of Pradhan Mantri Jan Arogya Yojana (PMJAY) for insurance coverage of in-patient care and Health and Wellness Centres (HWC) for primary care. In 2018-19, the scheme was announced with much fanfare, but with a much lesser allocation of Rs 2000 crore, making it equivalent to just Rs 40 per person, too little to provide for any meaningful coverage. The small allocation received its fair share of criticism. With the Loksabha election of 2019 approaching, the budget allocation for the scheme was increased to Rs 6400 crore in the year 2019-20 but subsequently was revised again to Rs 3200 crore.
Once again in the recent budget of 2020, the Finance Minister has reallocated Rs 6400 Cr to this scheme. These inadequate allocations and revisions in allocated budgets are not helping the scheme any better. The ratio of contribution towards premium between Centre and State is 60:40, which amounts to a collective allocation of Rs 10666.67 crore, i.e., Rs 1066.67 per family and Rs 213 per person. Even in this enhanced budgetary allocation, it is nigh impossible to meet the declared objective with a yearly premium this meager. According to alternative estimates, AB-PMJAY requires an annual budget of approximately Rs 20000 crore once it reaches its full coverage. So far in this crisis, only a handful have utilized this scheme for free COVID testing, rendering it virtually ineffective in this crucial period.
It’s said that the devil is in the details. Reading the fine print tells us that the gross budgetary support for AB-PMJAY in the year 2020-21 is only 200 Cr and remaining 6200 Cr will be supported by National Investment Fund. This means revenue generated from disinvestment of Central Public Sector Enterprises will be channelized to private secondary and tertiary healthcare enterprises through AB.
In fact, when the program was announced apprehensions were raised on several accounts- that it does not provide for the cost incurred on out-patient care-the major chunk of out of the pocket expenditure- or that instead of reviving a chronically underfunded and ailing public health system, it is likely to push more people into the private sector. Preliminary data from the National Health Authority reveal that the concerns were not unfounded. Between April 1 and November 21 only a third of the total allocation on PMJAY was spent, and 66% of the patients who availed service under the scheme, went to the private sector. So public money filled up private coffers, but when the same public needed them most, the private sector chose to look the other way, leaving the tottering public sector alone to do the heavy lifting.
HWCs, the other component of AB, currently number at 40557. Meeting the goal of transforming 1.5 lakh Sub Centres (SC), Primary Health Centres (PHC) and Urban Primary Health Centres (UPHC) into HWCs by 2022 would mean an addition of 3648 new HWCs every month henceforth. Considering the task of scaling up of SCs to IPHS standards (more than 90% currently do not meet the standards), provisioning of free drugs and diagnostic facilities, maternal and child health services, etc., the current allocation is far too insufficient. The per cent increase in the budget estimate of 2020-21 compared to the revised estimate of 2019-20 is zero as fund allocation is stagnant at Rs 1350 crore over the past two years.
The tremendous work done by the peripheral health workers at SC, PHC level may not have received enough coverage. Still, they remain the backbone of our containment strategies, tirelessly conducting contact tracing, tracking migrant workers, or doing door to door surveys, often without an adequate supply of PPE. With potential community transmission, the HWCs are expected to play a more prominent role as COVID management would require integration across different levels of care, from primary to tertiary.
Research has shown that epidemics tend to have gender unequal impact, affecting women differently in different spheres of their lives. The lockdown has intensified domestic workload, reduced livelihood opportunities, increased health risk of pregnant women and infants, and exposed a large section of women to domestic violence. It has also forced about 3.5 million women frontline-workers to work in precarious conditions with little support, protection or compensation from the government. For instance, the health insurance scheme announced for health workers infected with COVID only compensates for death, not hospital admission or treatment.
In March 2020, institutional deliveries declined by 43% compared to the same period last year. Once data for the next two months arrive, the numbers could be even more worrying. Institutional delivery is the primary strategy in reducing Maternal Mortality Ratio (MMR). The budget of 2017-18 had ambitiously set a target to bring down MMR to 100 by 2018-20 and Infant Mortality Rate (IMR) to 28 by 2019, while subsequently, the funds allocated to Ministry of Women and Child Development (MWCD), were slashed. Between 2019-20 and 2020-21 budgets, the rise in MWCD’s funding was modest, unlikely even to cover the impact of inflation.
Another scheme, Pradhan Mantri Matru Vandana Yojana (PMMVY), provides financial assistance of Rs. 5000 to pregnant women, only for their first issue. Rs 2700 Cr was earmarked for the scheme in 2017, 300 crores less than what was required to cover around 50 lakh women per year. But in the year 2018, budget for this scheme was further reduced by another 300 crores. An RTI query found only half the eligible women received PMMVY benefits in 2018-19. Despite a clear need for increased funds, the allocation has remained stagnant at Rs 2500 crore over the last two budgets.
Similarly, the Sabla scheme, important for the health of adolescent girls, had a Budgetary allocation of 300 crores in 2019-20, which was then reduced in half to 150 crores in the revised estimates. In the 2020-21 budget, the scheme received Rs 250 crore, which is less than the previous year’s allocation.
Budget estimates vs actual spending on health
Analysis of the previous six year’s Budget Estimate (BE) allocated to MoHFW shows fluctuating trends with negative growth of -14.42 per cent in the year 2015-16 and highest positive growth of 23.94 per cent in the year 2017-18. There is an average increase of 11.24 per cent in BE overall. This year (2020-21) the percentage increase (3.5 per cent) in the BE is the lowest among all six health budget estimates.
In the last six years, Revised Estimate (RE) and actual spending were also fluctuating than initial budget allocations with average 1.67 per cent increase in RE (lowest -14.50 and highest 12.55 per cent) over BE and average -1.29 per cent increase in actual expenditure (lowest -16.99 and highest 8.51 per cent) over BE. It shows that on average, the government is actually spending less than the budgeted estimates.
Health for all now
India, having one of the lowest public investments on health, is clearly spending less, and that too is done extremely erratically, hampering consistent support to programs integral to better health outcomes. Its budgets may be populated with big-ticket announcements, but they suffer from a bigger lack of substance. But now, more than ever, the government needs to put its money where its mouth is.
The COVID pandemic has highlighted the need of strengthening public health systems by expanding healthcare infrastructure, increasing health research capacity, plugging the gap in human resources, enhancing supportive care for the unequally impacted, and improving the overall social determinants of health. However, given the utter failure of the insurance scheme or the private sector in this moment of need, some course correction is warranted. There is already a growing clamour for strengthening of public health systems. A robust public health system is not only a prerequisite of pandemic preparedness but also essential for the health of the public, even during normal times. The government needs to think hard and think now about these demands of universalizing free and comprehensive public healthcare services, unless we want a repeat of the same health and humanitarian crisis when the next pandemic strikes.
The authors are Doctoral students, Centre of Social Medicine and Community Health, Jawaharlal Nehru University