4 min read.Updated: 01 Feb 2021, 10:23 PM ISTK. Srinath Reddy
The nation was awakened by the pandemic to the realities of sustained neglect and underfunding of the health sector
If you need objects to look bigger, use a magnifying lens. The finance minister did that deftly to project a 137% increase for health and wellbeing, by tying together healthcare, nutrition, water, sanitation and environmental protection. It is entirely appropriate to look also at health beyond healthcare, both from a public health perspective and in conformity with the sustainable development goals on health. However, those looking for a big boost to the health ministry’s programme budgets will have unmet expectations.
The nation was awakened by the pandemic to the realities of sustained neglect and underfunding of the health sector. The economic and social distress caused by rapid and extensive covid-19 virus transmission and stringent lockdown highlighted the interlinkages between health and the economy. It created a societal consensus for strengthening health systems to prevent avoidable deaths, promote wellbeing and provide timely and affordable healthcare.
Did the Union budget live up to its expectations by mobilizing and allocating substantial resources? The financial allocation for the upcoming fiscal year involving core health sector, including health and family welfare, health research and AYUSH, has been pegged at ₹76,902 crore against the previous year’s allocation of ₹69,233 crore, a modest rise of 11%. However, if last year’s revised estimates of spending were to be considered, it points to a decline of 10%. As a result, the centrally sponsored schemes (NHM and Ayushman Bharat) will witness a decline of 8% in allocation in the next fiscal as against last years’ revised estimates. Even while meeting the challenges of the pandemic, the major health programmes that are the vehicles of universal health coverage must continue to receive greater support.
The National Health Mission is expected to receive a relatively modest rise of just 4% in the next fiscal compared to revised estimates of the previous year. The Pradhan Mantri Jan Arogya Yojana (PMJAY) has received ₹6,400 crore in the budget estimates with similar amounts allocated last year. However, its utilization compared to last years’ allocation was less than 50%. This highlights three challenges: two brought about by covid-19, wherein substantial decline in utilization could be attributed to barriers of access to hospital services during lockdown, a sharp fall in utilization of non-covid-19 packages and inadequate availability of eligible hospitals in smaller cities and towns. The uptake of hospitalization, through the PMJAY scheme for covid-19 care, accounted for 4% of all hospitalizations during April to December 2020. Apart from investing in public healthcare infrastructure and staffing to accredit more hospitals to deliver the promise of PMJAY, the scheme must extend coverage to outpatient care as well as essential diagnostics and medicines.
The urgency of scaling up covid vaccination across the country has been reflected in budget provision of ₹35,000 crore this year. This will free up the states to focus on strengthening the supply chain and delivery of vaccines at the frontline facilities. The allocation to covid- 19 vaccines follows through on central government initiative, which since January 2021, has spent about ₹360 crore on vaccines for healthcare and frontline workers.
The preparedness for future pandemics must rely on infrastructure strengthening and making it more agile. The budget allocation for communicable disease surveillance and strengthening of health surveillance infrastructure was pegged at roughly ₹12,000 crore. The long-neglected health infrastructure for disease surveillance has now received a considerable boost. Although covid is a communicable disease, its worst effects are manifest in those with non-communicable diseases– diabetes, hypertension, cardiovascular diseases, obesity and chronic respiratory diseases. Therefore, an allocation only for strengthening communicable disease surveillance is a sub-optimal solution. A more robust and coordinated response to the syndemic is required rather than a saliency bias that focuses only on infectious diseases.
A new centrally sponsored scheme, PM Ayushman Bharat Swasth Yojana, has been proposed to supplement the NHM. It proposes to add more rural and urban health and wellness centres, expand disease surveillance at block, district and metropolitan levels and strengthen the National Centre for Disease Control and its five regional branches. Though obviously catalysed by the pandemic, the surveillance system must become broad-based to cover a broad array of risk factors, pathogens and diseases. The proposal to strengthen One Health surveillance, linking microbial migration pathways from wildlife to veterinary and human populations, has been timely.
Despite the emphasis on expanding healthcare infrastructure, there was little said on building the health workforce needed to use it well to competently deliver the needed services. Is that left to the states? Perhaps the 15th Finance Commission recommendations on health will be a major source of funds for states to explore and scale up government spending on health. The just-released recommendations of the Commission propose a strengthening of rural and urban primary healthcare, routing of funds to local bodies, support for allied health professional training, upgrading of critical care services and prioritised allocation to northeastern hill states. A template for comprehensive, connected, continuous care now emerge for public sector health services, from health and wellness centres and local bodies to district and medical college hospitals. This should be utilised through stepped up allocations to follow, in both state and central budgets. The stimulus provided by the confluence of the pandemic, the union budget’s welding of health and wellness into a common commitment to promote and protect health in all dimensions and the Finance Commission’s espousal of primary healthcare and allied health workforce should be sustained beyond the pandemic.
A substantial rise in public financing for health is critical for bringing down households’ out-of-pocket expenses. This is a yardstick by which our progress towards universal health coverage will be measured. While a holistic approach to health and wellness is welcome, the need for increased public financing of healthcare should not be lost sight of. Over to the state budgets now!
Dr Sakthivel Selvaraj contributed to this column.
K. Srinath Reddy is president, Public Health Foundation of India.
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