A massive 137 per cent increase in the allocation for health was one of the main highlights of the 2021 Budget announcements. Social media was quick to explain that the surge was not for health alone but included funds for drinking water, sanitation, nutrition, AYUSH, health research, vaccination as well as grants assigned by the 15th Finance Commission. The actual share of Health and Family Welfare was pegged at only a third of the total allocation of Rs 2.24 lakh crore.
Pre-COVID, the health budget was Rs 69,000 crore. An additional Rs 14,000 crore was pumped in to strengthen the National Centre for Disease Control (NCDC) and defray the costs of COVID-related expenditure on research, supplies and vaccination for health and frontline workers. This huge and timely infusion of funds was commendable particularly as, so far, the off-take and implementation have both been efficient. Given the size of the country and its diversity, in handling the pandemic, India, and in particular its health system, have performed beyond expectations. In partial recognition of the sacrifices made, the budget should have set up a corpus fund to aid medical personnel facing unforeseen risks and challenges while confronting health emergencies.
The FM also announced a new centrally-sponsored PM Aatmanirbhar Swasthya Bharat Yojana which would subsume funding for over 18,000 rural and over 11,000 urban health and wellness centres, provide support for public health laboratories, establish critical care hospitals together with five regional branches and 20 metropolitan health surveillance units linked to NCDC. Likewise, the strengthening of health offices at 32 airports, 11 seaports and land crossings will strengthen the capacity to screen arrivals and movement between and across states during epidemics. The announcement will, however, translate into funds only when projects and programmes are formulated.
Four important things go to the root of what ails the health sector but these did not find place in the budget.
First, since Ayushman Bharat was launched in September 2018, crores of beneficiaries from the 50 crore eligible poor have received hospital care through cashless hospitalisation. But now the programme must additionally protect the poor from the uncertainties of doctor hunting, receiving irrational treatment from unqualified medical practitioners, provide drugs and address the inability to pay for high-end diagnostics. Unless the costs of outpatient treatment are catered for under Ayushman Bharat, heavy, out-of-pocket expenditure will continue before a patient needs hospitalisation.
Second, insurance coverage for the middle class remains a gap which should have been addressed through the budget. All citizens, whether employed in unorganised sectors or self-employed, need health cover. Comparisons with other countries do not imply that they are superior, but certainly their experience can be built upon. Among the high performing countries, Germany and France fund health care through contributions which are mandated by law and shared by the employer and employee. The Canadian system pays for all services based on need rather than the ability to pay. The Canada Health Act of 1984 makes federal cost-sharing a government responsibility and unlike the UK’s NHS, where one is linked to a local provider, in Canada healthcare entitlements are portable across the country. Such ideas could work for India’s middle class. The routine response is to dismiss any such suggestion by saying that over 90 per cent of the white-collar workers are in the unorganised sector and health being a state subject, it goes beyond the scope of the central budget.
But undeniably, whether organised or unorganised, everyone who has a job has an employer. After excluding some 50-crore people covered by the Ayushman Bharat health programme for the poor as well as the 10 per cent employee groups falling in the organised sector who are covered by different government or employer generated medical coverage schemes, it still leaves some 30 crore Indians without any state-supported medical insurance. Thanks to Aadhaar and any number of laws starting with the Shops and Establishments Act, 1948, it will not be difficult to collect information on employers and employees in the unorganised sector. All states can be incentivised to mandate the need for all citizens to possess government supported health insurance. If every employer and employee paid even a nominal share, it would cover the costs of essential healthcare to the unorganised sector middle classes.
The Employees State Insurance Corporation scheme created in 1948 through an Act of Parliament could also be modified and used. The then Finance Minister Arun Jaitley, in his 2015-16 budget speech, had announced that the government intended to bring an amending legislation. The ESIC has several shortcomings but nothing prevents government from enlarging its scope to go beyond blue collar workers to cover white collar employees in the unorganised sector. Its linkage with the labour ministry alone needs to be revisited.
Third, the absence of any mention of medical regulation based on the 2017 National Health Policy has once again left consumers without protection. The health policy had recognised that grading of clinical establishments would give protection to patient rights. The states have been tardy, even remiss, in not implementing the model Clinical Establishments Act 2010. The Indian Medical Association has successfully thwarted efforts to instil accountability in medical establishments for eleven long years. The Fifteenth Finance Commission’s recommendation to start a debate on bringing public health and hospitals on the concurrent list of the Constitution (like population control, food adulteration and drugs already are,) is a bold initiative. It merited a mention in the budget.
Fourth, the Health Policy 2017 had also recommended the establishment of a separate Empowered Medical Tribunal. The Consumer Protection Act 1986 was never mandated to address the complexities of medical negligence or malpractice. The health sector badly needs a regulator on the lines of the State and Central Regulatory Commissions, say, for electricity. Having been embedded in the Health Policy 2017, it behoved a mention of the need for health regulation.
As normalcy starts to return, basic health protection for Indians must no longer be bought. It must be assured through participation.
The writer is former secretary, AYUSH Government of India, and health secretary, Delhi government