Piecemeal interventions, an emphasis on private participation, and a slew of cosmetic announcements characterise the health budget of 2016-17. The attempt was ostensibly to project the government’s pro-poor face; if so, that exercise has proven to be a resounding failure given the low budgetary allocation and the emphasis on the private sector yet again for the delivery of critical health services. Notwithstanding the grandiose announcements of a health insurance cover of Rs.1 lakh a family in the below poverty line (BPL) category, an additional top-up cover for senior citizens, and the proposal to open 3,000 generic drug centres under the Prime Minister’s Jan Aushadhi Yojana, the overall estimated budget allocation shows only a minuscule increase over the Revised Estimates for 2015-16. It still falls far short of reaching the Twelfth Plan target of 2.5 per cent of the gross domestic product (GDP). The total allocation, according to the think tank Centre for Budgetary Governance and Accountability, remains at 0.25 per cent of the GDP at the present allocation levels.
In a first, the government has declared the setting up of a national dialysis services programme through private-public partnership (PPP) under the National Health Mission (NHM) where such services are envisaged to be provided at all district hospitals. The PPP model was actively propagated by the United Progressive Alliance government too and was underscored in the Twelfth Plan document, but it had never been declared in such an upfront manner as in the 2016-17 Budget. This is surprising considering the fact that several government documents and rural health statistics have consistently revealed the dependence of people on the private sector and the colossal debt incurred from out-of-pocket (OOP) expenditure on health. In fact, the recent 71st report of the National Sample Survey Office (NSSO) shows that 70 per cent of ailments are treated in the private sector and the average amount spent for treatment per hospitalised case in the private sector is four times that spent in public hospitals. The meagre budget allocation therefore does little to address this anomaly as far as access to treatment and affordable health care is concerned.
The Jan Swasthya Abhiyaan (JSA), an umbrella organisation for various groups and individuals working in the health sector, expressed its disappointment with the allocations for the health sector. The budget provisions for health care, it said, indicated that the government intended to continue with its policy of promoting “managed care” where publicly provided services were progressively starved of resources and public-funded services were increasingly outsourced to the private sector.
While the overall allocation to the Ministry of Health and Family Welfare (MoHFW) has gone up from Rs.32,819 crore in the Revised Estimates for 2015-16 to Rs.37,061 crore in the Budget Estimates (after adjusting for receipts) for 2016-17, this represents a mere 8 per cent increase after adjusting for inflation and a 5 per cent per capita increase if adjusted for population increase. “Even the grossly understated ambition of the draft National Health Policy—which continues to be in limbo for almost a year—is to increase health-care expenditure to 2.5 per cent of GDP. This would require a doubling of the current expenditure, and even simple mathematics would indicate that this would entail a 25-30 per cent per capita increase in allocation every year, if the target of 2.5 per cent of GDP spending on health care is to be achieved in the next five years,” said a statement issued by the JSA. Interestingly, it also highlighted that the current allocation on health care was roughly the same as the profit earned (after tax deduction) of the country’s pharmaceutical industry, at Rs.32,733 crore according to the Budget papers.
What is more worrying is that the government’s flagship programme to strengthen the public health system, the NHM, has seen only a marginal increase in allocation, from Rs.19,135.37 crore in 2015-16 to Rs.19,437 crore. Given the impact of inflation and population increase, this actually represents a 6-7 per cent decrease per capita. The underfunding of the NHM, the JSA stated, had to be read in the light of the draft National Health Policy’s comment that “strengthening health systems for providing comprehensive care required higher levels of investment and human resources than were made available. The budget received [for the National Rural Health Mission] and the expenditure thereunder was only about 40 per cent of what was envisaged for a full revitalisation in the NRHM framework.”
The JSA pointed out that while there was a deliberate intent to choke financial resources available to public health services through the NHM, the declaration of an expansion of the public-funded health insurance scheme failed to consider the innumerable reports and studies pointing out the failure of existing national and State health insurance schemes against the catastrophic health expenditure incurred by the poor. “These schemes, largely implemented through partnerships with private providers, have been indicted in several States for defrauding the system of hundreds of crores by performing unnecessary surgeries (for example, a huge rise in unnecessary uterus removal operations) and for not contributing to better health outcomes,” the JSA noted.
Critics say the National Dialysis Service Programme in PPP mode is another scheme of burdening and indebting the poor. While there undoubtedly is a real need to make available free-of-cost dialysis services in public facilities, the scheme seems to be directed at further outsourcing clinical services to the private sector. The JSA statement noted that it was unclear as to how such a scheme would provide real benefits without a concomitant increase in public services to diagnose and treat kidney disorders. Nor was it clear how the resources for such a scheme would be harnessed given that the budget for the NHM had been slashed. The real need, said Amit Sengupta on behalf of the JSA, was to increase the allocation for the NHM so that public facilities were able to provide access to a range of clinical services free of cost.
Jan Aushadhi centres
The allocation of Rs.35 crore for 3,000 Jan Aushadhi centres, a welcome plan, is also said to be grossly meagre. Moreover, systemic issues underlining the failure of the previous avatar of the scheme—such as the inability of the Medical Council of India to enforce prescriptions by generic name—still remain. The budget also did not seem to take into consideration the pitiable shortages in medical manpower and infrastructure, as mentioned in the 92nd Department-related Parliamentary Standing Committee Report on Health and Family Welfare tabled in Parliament on March 8. According to it, despite having the largest number of medical colleges in the world, and currently having approximately 9.29 lakh doctors in the Indian Medical Register, India is way behind in achieving the targeted doctor-population ratio of 1:1,000 as per World Health Organisation norms. Shortage of doctors has derailed both access to and quality of health care, especially to the poor, the report says.
Citing the Report of the Group of Experts constituted by the MoHFW to study the Indian Medical Council Act, 1956, which highlighted the magnitude of the gap in health care services, it states:
“While many important health-care indices, such as life expectancy, infant and maternal mortality have improved significantly since Independence, we lag woefully behind developed countries and even other countries with similar socio-economic status as ours, in these indicators. India’s Under 5 Child Mortality (probability of dying before reaching age of 5 per 1,000 live births) as in 2011 was 61, as compared to Nepal 50, Bhutan 54, Bangladesh 46, Peru 18, Maldives 15, China 15, Brazil 16, Thailand 12, Sri Lanka 12, Chile 9, the United States 8, Cuba 6, the United Kingdom 5, Japan 3 and is slightly better than only Pakistan 88. Maternal mortality figures (number of maternal deaths per 100,000 live births) are worse: India 200, Bhutan 180, Nepal 170, Brazil 56, Thailand 48, Sri Lanka 35, China 37, Chile 25 as compared to the U.S. 21, the U.K. 12, Japan 5, Singapore 3.”
According to the government’s draft National Health Policy 2015: “Over 63 million persons are faced with poverty every year due to health-care costs alone. People have no financial protection for the vast majority of health-care needs. In 2011-12, the share of out-of-pocket expenditure on health care as a proportion of total household monthly per capita income was 6.9 per cent in rural areas and 5.5 per cent in urban areas. This led to an increasing number of households facing catastrophic expenditure due to health costs (18 per cent of all households in 2011-12 as compared to 15 per cent in 2004-05).”
Public funding is estimated to be of the order of only 19.67 per cent of the expenses of health care in the country (according to the National Health Accounts Estimates 2004-05) and most of the private expenditure is OOP expense, which has the potential of pushing even the non-poor into poverty.
The Parliament Standing Committee report also dwells on the high degree of dependence on the private health care sector, a corollary of the absence of robust and widespread health care services in the public sector. Citing Rural Health Statistics, 2015, the Parliamentary Standing Committee report points out that there were only 25,308 primary health centres (PHCs) as on March 31, 2015, for a rural population of 83.3 crore plus. These PHCs suffered from staff shortages too. The shortfall of allopathic doctors at PHCs vis-a-vis the requirement based on the existing infrastructure was 11.9 per cent. “Moreover, as compared to [the] requirement for existing infrastructure, there was a shortfall of 83.4 per cent of surgeons, 76.3 per cent of obstetricians and gynaecologists, 83.0 per cent of physicians and 82.1 per cent of paediatricians. Overall, there was a shortfall of 81.2 per cent specialists at the CHCs [community health centres] as compared to the requirement for existing CHCs.”
There has been a steady increase in vacancies in the positions of doctors at PHCs over the last five to 10 years (27 per cent in 2015) and an even more shocking increase in the vacancies of specialists at secondary facilities. “The current position of specialists manpower at CHCs reveal that as on March 31, 2015, out of the sanctioned posts, 74.6 per cent of surgeons, 65.4 per cent of obstetricians and gynaecologists, 68.1 per cent of physicians and 62.8 per cent of paediatricians were vacant. Overall, 67.6 per cent of the sanctioned posts of specialists at CHCs were vacant.” Thus, the report notes, people who live far from cities and towns have no option but to travel long distances for surgical care. Further, according to the Report of the Working Group on Tertiary Care Institutions for the Twelfth Plan, rates of infant and maternal deaths are still high; nearly one million Indians died every year because of inadequate health care facilities, 700 million people had no access to specialist care, and 80 per cent of the specialists were working in urban areas. Despite India’s economy today being one of the world’s fastest growing and the third largest in terms of Gross National Health Income, the country’s health care system continues to face a huge gap in terms of access to adequate health care and availability of health professionals and facilities.
Given all these indicators, the budgetary allocation for health comes nowhere near achieving universal health care or coverage for all. The Union Budget’s pick-and-choose and silo-based approach to health is in complete disregard for what its own reports and data point out in terms of what is required for the nation’s health.