The ministry of health and family welfare received an increase of nearly Rs10,000 crore in the budget for fiscal 2017-18, the fourth presented by finance minister Arun Jaitley. Considering the high priority accorded to infrastructure and digital economy in this budget, it is a relief that health got even this modest rise in allocation. However, the big questions are whether this can meet the ambitious goals set for the health sector in the budget speech and if the increased allocation will be utilized for the right priorities.
The finance minister’s announcement that 150,000 health subcentres will be transformed into health and wellness centres is a welcome initiative for strengthening primary health care. This will require more frontline health professionals to be employed and technology-enabled. Skilled community health workers and allied health professionals will be needed in large numbers. The Economic Survey’s call for strengthening programmes for maternal health and child nutrition also requires greater investment—for universalization of the Maternity Benefit Programme, improved quality of services for safe childbirth and neonatal care at institutions where women report for delivery, and protected early child development. The increase in allocation for schemes related to women and child welfare, across all ministries, is Rs24,000 crore. However, the increase in allocation for the National Health Mission (NHM), which is the main vehicle for maternal and child health, is only Rs5,500 crore. Keep in mind that the National Urban Health Mission component of NHM is yet to take off and will also require substantial resources for scale up.
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A series of ambitious targets have been set: eliminating kala azar and filariasis by 2017, leprosy by 2018, measles by 2020 and tuberculosis by 2025; reducing the infant mortality rate from 39 in 2014 to 28 by 2019 and cutting the maternal mortality rate from 167 in 2011-13 to 100 by 2018-2020. While these targets should galvanize the health ministry, the allocated resources seem inadequate for gearing up the health systems across the country in time. Even while accelerating to move from second gear to top gear, we must make sure there is enough fuel in the tank for the full journey. Even well-intended vertical programmes cannot be force-fitted into a feeble health system.
An emphasis on secondary and tertiary care has seen a call by the finance minister for 5,000 more postgraduate medical seats to train more specialists. While the proposal to expand the diplomate of national board programmes in district hospitals is welcome, there should be no rush to raise the number of seats in private medical colleges which charge a hefty capitation fee. The proposal to fund two new more All India Institutes of Medical Sciences, in Gujarat and Jharkhand, appears hasty when the several new institutions started in the past decade are facing serious challenges in getting faculty and meeting educational standards. While the budget signals its intent to transform the regulatory framework of medical education and practice, no specifics have been provided.
The budget is stunningly silent on the National Health Protection Scheme, which was expected to replace the Rashtriya Swasthya Bima Yojana in April 2017. Will the advocacy of a Universal Basic Income (UBI), made in the Economic Survey, lead to abandonment of Universal Health Coverage (UHC) as a government-led initiative? All welfare schemes should not be substituted by the UBI. The government should clearly affirm its commitment to UHC, especially as it is now a defining feature of the Sustainable Development Goal on health. Countries where UBI is being considered, such as France, already have UHC and UBI will be an additional entitlement, not an alternative.
The government also proposes “to amend the Drugs and Cosmetics Rules to ensure availability of drugs at reasonable prices and promote the use of generic drugs”. New rules for regulating medical devices will also be formulated. These are highly desirable and long overdue initiatives. Providing essential drugs free of cost at public facilities and wide availability of inexpensive generic drugs in the market would reduce the outrageously high out-of-pocket expenditure on health. Given US President Donald Trump’s pressure on the multi-national pharmaceutical industry to ‘make in America’, the Indian generic industry must look for other global markets and needs support from the Indian government to remain a viable and valued source of affordable medicines. Other welcome measures include disabled-friendly facilities in 500 railway stations, listing of health conditions on Aadhaar cards of senior citizens, scaling up of Swachh Bharat, safe drinking water for 28,000 arsenic- and fluoride-affected areas and an increase in tobacco taxes. Alas, beedis have again eluded the tax net. We have to wait for the goods and services tax to get a clear picture of tobacco taxes as they evolve.
K. Srinath Reddy is president, Public Health Foundation of India.