The Economic Survey 2020-21 and the finance minister’s budget speech in Parliament raised hopes that, in response to the lessons of the COVID-19 pandemic, there would be an increase in allocation to public health services. The Economic Survey argues for the need to increase public spending on healthcare to 2.5-3 per cent of the GDP — it’s about 1.5 per cent currently. The survey underlines that public services are crucial for taking the weight of out-of-pocket-expenditure on medical services off peoples’ back. It points out that there is not much difference in terms of outcomes and quality between healthcare services in the private sector and such services in public centres. The Economic Survey, therefore, calls for strengthening the National Health Mission (NHM) along with Ayushman Bharat — NHM was initiated in 2005-06 to strengthen the public health services and the Ayushman Bharat scheme was rolled out to provide social insurance, thereby financing private sector services with public funds.
The Economic Survey makes a strong pitch for greater regulation of health services in the private sector. In doing so, it echoes the demands made by public health analysts and health movements or decades. The country’s common citizens are, of course, desperately on the lookout for trustworthy, accessible and affordable health services.
The finance minister carried this narrative further in her budget speech, describing “health and well-being” as one of the pillars of the budget and announcing a 137 per cent increase in allocations for it. She placed healthcare, water and sanitation and nutrition as the key components of this pillar. She announced a new scheme, the Pradhan Mantri Atma Nirbhar Swasthya Yojana, to support the almost 29,000 health and wellness centres in the country. The scheme also envisages the creation of public health laboratories and critical care hospital blocks and virology institutes. The FM underlined the importance of the concept of “One Health”. All these are important to strengthen the capacities of the public system to respond to health needs.
However, the figures in the budget documents reveal a different story. They show an absolute increase of 9.6 per cent in allocations for the Department of Health and Family Welfare (that includes NHM and Ayushman Bharat). A 26.8 per cent increase for the Department of Health Research and 40 per cent increase for the AYUSH Ministry do not add up to much since each of them are only 3-4 per cent of the total health budget. A Finance Commission grant of Rs 13,000-crore and Rs 35,000-crore for COVID-19 vaccination are one-time allocations and, therefore, do not strengthen the overall system. The core health service and research ministries (H&FW and AYUSH) have together received only an 11 per cent increase.
Even in COVID times, the health services get only 2.21 per cent of the total central budget — down from 2.27 per cent in the 2020-21 budget. Computing for inflation, the increase in allocation for health services alone disappears and actually becomes negative.
Water and sanitation received a 179 per cent increase over the previous year’s allocation (from Rs 21,518 crore to Rs 60,030 crore) already earmarked for the flagship schemes, Swachh Bharat and Jal Jeevan Mission. But allocation for nutrition decreased by 27 per cent, with the “new” Poshan 2.0 merely combining the poorly performing Supplementary Nutrition Programme and Poshan project. Added together, health, water and sanitation and nutrition make up the claimed 137 per cent increase in allocation to “health” services — with a real decline in healthcare and nutrition.
The new Pradhan Mantri Atma Nirbhar Swasthya Bharat Yojana (PMANSY) has an announced allocation of Rs 64,180 crore over six years, but it does not find a place in the present budget documents. Does that mean it is a statement of intent and the scheme is likely to get funds from next year? The intent to strengthen primary, secondary and tertiary service institutions is indeed welcome. But one wonders why these additional activities have not been slotted in the NHM. Since 2014, the allocation for NHM has been on the wane, and, therefore, even the marginal 1.33 per cent increase (from Rs 27,039 crore to Rs 30,100 crore) is a demonstration of the government’s realisation that public services do matter. How far the allocations of about Rs 10,000-Rs 11,000 crore each year for the PMANSY will go in making the public services capable of “universal health coverage” and minimise out-of-pocket-expenditures is the moot question. The High-Level Expert Group on Universal Health Coverage had estimated that by 2020, we need a 114 per cent increase in sub-centres and primary health centres, 179 per cent increase in community health centres and a 230 per cent increase in sub-district and district hospitals. Getting anywhere close to this requires doubling of real allocations every year over a five-year period to reach something like 10 per cent of the budget. In the present budget, it declines to a mere 2.21 per cent.
If such public provisioning for universal health coverage seems too much of a dream, then effective low-cost rationalised service system options have to be designed. Insurance schemes only create the mirage of affordability of health services while adding to peoples’ expenses. Community and public services are indisputably the most cost-effective for any society.
Water and sanitation are meaningful for health, but not if it only inflates the allocation to “Health and Wellbeing” to create an illusion of responding to health imperatives. In that case, it is only diverting attention from the urgent task of designing an effective universal health care system.
The writer is professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi