In 2011, a high-level expert group on universal health coverage reckoned that nearly 70% of government health spending should go to primary health care. The National Health Policy (NHP) 2017 also advocated allocating resources of up to two-thirds or more to primary care as it enunciated the goal of achieving “the highest possible level of good health and well-being, through a preventive and promotive healthcare orientation”. However, if current trends and projections are anything to go by, this goal is likely to remain a pious hope.
Towards a national health policy
Last year, an outlay of ₹1,200 crore was proposed to transform 1.5 lakh sub-health centres into health and wellness centres by 2022, which would provide a wider range of primary care services than existing sub- and primary health centres (PHC). Going by the government’s own estimate, in 2017, it would cost ₹16 lakh to convert a sub-health centre into a health and wellness centre. This year, the outlay is ₹1,600 crore (a 33% increase) clubbed under the National Health Mission (NHM) budget. Assuming that at least the same number (15,000) of new health and wellness centres would be planned for 2019-20, and that at least half the aforementioned amount of ₹16 lakh would be required to run an already approved health and wellness centre, the required sum for the year 2019-20 stands at around ₹3,600 crore. While this is a conservative estimate, the realistic figure could easily exceed ₹4,500 crore. The current outlay is less than half the conservative estimate — not to mention that building health and wellness centres at the given rate (15,000 per year) can fulfil not even half the proposed target of 1.5 lakh health and wellness centres till 2022.
The overall situation with the NHM, India’s flagship programme in primary health care, continues to be dismal. The NHM’s share in the health budget fell from 73% in 2006 to 50% in 2019 in the absence of uniform and substantial increases in health spending by States. The medium-term expenditure projection statement presented by the Ministry of Finance to Parliament in August 2018 projected a 17% increase in allocation for the NHM in 2019-20. However, there has only been only an increase of 3.4% this year. With this, the NHM budget for this year (₹31,745 crore) barely crosses the actual spending on the programme in 2017-18 (₹ 31,510 crore).
Breathing life into health care in India
On the other hand, the Centre looks fairly committed to increasing access to hospitalisation care, predominantly through private players. This reflects in the 167% increase in allocation this year for the Pradhan Mantri Jan Arogya Yojana (PMJAY) — the insurance programme which aims to cover 10 crore poor families for hospitalisation expenses of up to ₹5 lakh per family per annum — and the government’s recent steps to incentivise the private sector to open hospitals in Tier II and Tier III cities. The increase in the PMJAY budget is a welcome step — spending on this colossal insurance programme will need to rise considerably with every passing year so that its commitments can be met. However, the same coming at the expense of other critical areas is ill-advised.
Today, the condition of our primary health infrastructure is lamentable: there is a shortage of PHCs (22%) and sub-health centres (20%), while only 7% sub-health centres and 12% primary health centres meet Indian Public Health Standards (IPHS) norms. Further, numerous primary-level facilities need complete building reconstruction, as they operate out of rented apartments and thatched accommodations, and lack basic facilities such as toilets, drinking water and electricity. Data by IndiaSpend show that there is a staggering shortage of medical and paramedical staff at all levels of care: 10,907 auxiliary nurse midwives and 3,673 doctors are needed at sub-health and primary health centres, while for community health centres the figure is 18,422 specialists.
Doctors for rural India
While making hospitalisation affordable brings readily noticeable relief, there is no alternative to strengthening primary health care in the pursuit of an effective and efficient health system. It must be remembered that the achievement of a “distress-free and comprehensive wellness system for all”, as enunciated by the Union Finance Minister in this year’s Interim Budget speech, hinges on the performance of health and wellness centres as they will be instrumental in reducing the greater burden of out-of-pocket expenditure on health. Their role shall also be critical in the medium and long terms to ensure the success and sustainability of the PMJAY insurance scheme, as a weak primary health-care system will only increase the burden of hospitalisation.
The government needs to remember its promise of ‘Health assurance to all’ made in its election manifesto in 2014. Apart from an adequate emphasis on primary health care, there is a need to depart from the current trend of erratic and insufficient increases in health spending and make substantial and sustained investments in public health over the next decade. Without this, the ninth dimension (‘Healthy India’) of “Vision 2030” will remain unfulfilled.
Soham D. Bhaduri is Chief Editor, ‘The Indian Practitioner’, and a medical doctor based in Mumbai
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