Health is a State subject but with the Finance Commission’s advice to move it to the Concurrent list, in future we can expect higher budgetary allocations by the Centre
The Union Budget has always been the reflection of how we prioritise and allocate limited resources to the efforts of nation-building and nurturing across sectors. While India has set aspirational targets regarding the 2030 Sustainable Development Goals (SDG) we are one of the nations with the lowest Government spending on healthcare (less than two per cent), with the highest burden of communicable diseases like Tuberculosis (TB) while bearing an epidemiological transition towards a crescendo of non-communicable diseases. India aspires to invest about 2.5 per cent of the GDP into healthcare by 2025, which is a lower target than the global average of six per cent. At the same time we aspire to end the epidemics of TB, AIDS and malaria by 2030. In some ways we are making progress and moving forward but are we putting enough on the table?
Most of the SDG goals that India aspires to achieve, as per the NITI Aayog SDG Index, are aligned towards primary care and human resources for health. It selects indicators for reducing maternal mortality, under-five mortality and TB burden while increasing immunisation coverage and human resources for health. The National Health Mission, including rural and urban, (NRHM and NUHM) is the core of the healthcare delivery services and thus will be the conduit to deliver on the promises of better health. NRHM has received a marginal increase of seven per cent to reach Rs 27,039 crore while NUHM was allocated Rs 950 crore, a nine per cent increase from the previous year. A large part of this Budget, Rs 1,550 crore has been earmarked for the development of Health and Wellness Centres (HWCs). About 1.5 lakh HWCs envisioned for 2022 and 40,000 centres to be built by 2019-20 allow for about Rs 4 lakh per centre (considering both years’ budgets), which is a pittance given the aspiration of infrastructure upgrade and manpower needed.
The Government claims that 28,500 HWCs have been established and to strengthen the primary and preventive care foundations, there needs to be more focussed cash-flow and implementation at the first level of contact with the patients. On the optimistic side, there is a 94 per cent increase in ASHA benefit package (Rs 400 crore) which is a great step towards ensuring delivery at the last mile. ASHA workers being the face of almost all health schemes and services, this has the potential to impact all four SDG India Index indicators.
Tertiary care schemes, however, have seen their funds being jettisoned. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) received only Rs 175 crore as opposed to Rs 300 crore in 2017-18. Keeping in mind the increasing burden of non-communicable diseases and the focus on screening at the HWCs, there needs to be a higher allocation of cash towards this programme.
The National Mental Health Programme, which saw a budget estimate of Rs 50 crore but a dismal revised estimate of Rs 5.5 crore in the previous Budget, has again received a budget estimate of only Rs 40 crore. It remains to be seen how much is finally allocated to this programme but as a nation we are still neglecting mental health issues that are silently affecting everyone across the socio-economic spectrum, from industrialists to numerous college students.
The National Crime Records Bureau mentions that in 2015, a whopping 8,934 student suicides were recorded in India. A much larger number goes unreported. It would be encouraging to see more efforts made towards the much-neglected mental health delivery system.
No discussion is complete without perspectives on the Ayushman Bharat (AB) insurance scheme. The previous two Budgets saw a more than two-fold increase in commitment from Rs 2,400 crore to Rs 6,400 crore and it is fair to expect that the allocation will increase. While the initial plan was to cover 10 crore families, there have been aspirations to cover 50 crore. However, the challenge here is not allocation of money but optimal utilisation of it. While on one hand demand has been created, there is a deficit in the supply of health services as well as a reticence in current capacity of healthcare providers to participate, given the challenging pricing of the health packages.
The massive demand and the challenging prices claiming margins at scale can only be serviced by a greater supply of the healthcare delivery taskforce. This is also reflected in SDG 3.8 (human resources for health) and is the most critical piece of the healthcare puzzle, without which all other efforts will fall short. According to the Global Health Workforce Alliance, India falls in the category of countries with a “risk of severe crisis in availability of human resources for health.” Against the WHO-recommended 22.8 (revised 44.5) qualified health professionals per 10,000, India only has 16 (adjusted for qualification) per 10,000. This massive gap is either completely un-serviced or is filled by quacks.
We have often seen fallouts of this in overpopulated, understaffed Government hospitals. Last year, scores of children died due to Acute Encephalitis Syndrome in Muzaffarpur in Bihar. A condition manageable by adequate medical care, the deaths were attributed to malnutrition of the children and poor logistics in the hospital(s).
The issue of workforce shortage affects the entire health ecosystem but the gargantuan demand created by AB will highlight the challenges much more, with a higher relative demand-supply gap shaping up. Private hospitals that are not participating in the specific health service packages or as a whole in AB are already saying that the high volume, low margin play is not realistic since they are limited in capacity of skilled workforce. In the absence of a commensurate health workforce, the hospitals will never reach the scale at which the volumes can be serviced so that the low margins will make sense with the challenging prices.
In areas where fundamental health infrastructure (both public and private) itself is low, the scheme is bound to have low adoption. This is reflected in minimum utilisation of the scheme in the North-eastern States, Daman and Diu and Dadra and Nagar Haveli, where the supply for health services is extremely low. We need more doctors, nurses and allied staff with institutions to train them. Investments are required towards building more public institutions for training.
There has been only a 0.7 per cent increase in the Budget for human resources for health and medical education in the last two years. Most of the Budget has been allocated to increasing undergraduate seats at existing institutes and postgraduate seats in district hospitals. The Budget for creating new medical colleges has been reduced to Rs 2,000 crore, the lowest in the last three years. If we increase seats in existing colleges, without creating new ones, we walk a thin line of quality education trade off with quantity as the number of medical college seats to number of beds in its associated hospital is a fixed ratio, maintained to safeguard quality education. It is here that the NITI Aayog has proposed allowing private medical colleges to work with public district hospitals to generate more medical seats in their paper Scheme to link new and/or existing private medical colleges with functional district hospitals through PPP. This could potentially be a way to bring in some numbers for the skill pool but needs careful craftsmanship to keep the public sentiments at the centre for care delivery while allowing enough room for market forces to sustain. Additionally, the outlay for paramedical and allied health services has been dismal. The Budget for setting up state institutions for paramedical training has been a pitiful Rs 20 crore, same as 2018-19. Strengthening of nursing services received only Rs 64 crore while pharmacy colleges received a paltry Rs 5 crore. The need for upskilling allied health skilled professionals is more pressing now than ever, at the face of absolute and relative shortage of doctors to serve the impending gargantuan demand. It would be encouraging to see the same being reflected in the pecuniary commitments. Only then can we create an ecosystem of health services, public and private, that can serve the ambitions of the AB at the desired nexus of quality and cost. Since health is still a State subject, the Centre’s contribution is limited to infrastructure development. With a more rights-based approach to health and the Finance Commission’s recommendations to move it to a Concurrent subject, in the near future we can expect greater accountability and thus higher budgetary allocations by the Centre. Till that time, it needs to support the trailing States more so that health infrastructure can be built and markets be created for AB to find takers.
(Writer: Debanshu Roy; Courtesy: The Pioneer)