Compared to the West, our health budget is still far from 5% of GDP. We will be happy if this figure settles at 4%.
With the presidency of G20 started and having gone through the worst-ever health impact on the nation’s health during the pandemic, expecting a decent health budget wasn’t wrong. I was surprised to see the health outlay maintained at 2.1% of GDP, almost same as that of last year. This is disappointing, especially for healthcare professionals, as others would hardly understand the intricacies of this sector. Though I had high expectations from the government for higher health outlay, after the Economic Survey tabled in the Parliament on 31 January, this figure was expected.
There is no denying the fact that health budgets have increased over the years from 0.3% of GDP in 1986 to around 1% in 2010; for FY 2019 it was 1.4% and for FY 2021 it was 1.6% and almost the same till FY 2021. There was a quantum jump to 2.2% of GDP for FY 2022 and that was mainly due to unplanned expenses incurred on Covid management. Last year it was 2.1% and the same is maintained this year too, though the increase in amount over last year’s health allocation is 2.7%.
Any ministry with a low budget has no takers. The Ministries of Health, Social Welfare, Women Welfare, Tribal Welfare are described as adjustment ministries for representation to political parties and some communities. A cursory glance at the health ministers during 1980-2014 shows they were often changed faster than seasons. Of the 21 health ministers, eight were from minority communities, four were from Tamil Nadu’s PMK party and three belonged to reserved classes. Without casting any aspersions on them, some had performed extremely well with fullest dedication like A.R. Antulay, Dr Anbumani Ramadoss and Sushma Swaraj. Others were holding on till they got better portfolios. This has changed and we see stability since 2009, commensurate to increasing health budgets.
Undoubtedly, ever since I started talking about the poor health-spending in India, with mere 0.3% of GDP in 1986, there has been a seven-times jump in 17 years. However, compared to the West (we want to in the G7 league), our health budget is still far from 5% of GDP. Taking into account the crucial facts—the cost of medicines, testing and consultations are proportionately far lower in India, we will be happy if this figure settles at 4%. Being born optimistic, and perusing the way India handled the Covid pandemic notwithstanding financial constraints, I was under the impression that steadily we will reach the healthcare allocation at 4% in the next few years. The Niti Aayog had promised to hike the health budget to 2.5% of GDP by 2025. Even for that goal, the health budget should have been 10% more or 2.3% of GDP.
Barring the setting up of 157 nursing colleges and higher allocation for research in the pharma sector, there is nothing outstanding in the health sector—it is business as usual.
SALIENT FEATURES
1. During the pandemic years, the health ministry was considered only next to the home ministry. The attention and discussion have been always around health consciousness, health advisories, RTPCR, ICMR, Niti Aayog, public health perspectives, Covid-appropriate behaviour, PPE, vaccination, pandemic preparedness, augmenting healthcare infrastructure, variants and sub-variants, genome sequencing—all related to health. India hasn’t yet withdrawn travel restrictions and Covid-protocols, despite no let-up in numbers—with weekly cases and deaths in double digits and single digit respectively. We haven’t declared an end of the pandemic. Then why was health downplayed? The entire speech of the Finance Minister had the word “health” for eight times of which only once it was truly concerning the subject of “health” per-se. The remaining were used in general parlance, concerning the growth of the country with health and education in it. Health doesn’t figure in the top ten departments for budget allocation.
2. Though the announcement was there of establishing 157 new nursing colleges, at co-location with 157 newly established medical colleges since 2014, it cannot be considered a large step. This should have been done gradually since 2014 itself. Traditionally, medical colleges have paramedical institutes like those for nursing, laboratory and radiology technicians, physiotherapy, occupational therapy as attachments and thus they co-exist being complementary to each other. What was indeed expected was establishing new medical colleges at district hospitals in districts without medical colleges.
3. Sickle Cell Anaemia Elimination Mission is indeed important, though the target of 2047 is too far. The sickle cell disease (SCD) is a genetic condition and is widespread only among the tribal population in India with about 0.8% births among Scheduled Tribes have SCD, more in Gujarat.
4. Medical Research: FY 24 budget states that facilities in select ICMR laboratories will be made available for research to public and private medical college faculty and private sector R&D teams for encouraging collaborative research and innovation. This has its origin in the development of Covaxin as a PPP model. But if you see the budget allocation of Department of Health Research (DHR) it is just Rs 2,980 crore or a mere 3.3% of the health budget and 0.07% of GDP.
5. Pharma Innovation: This new programme to promote research and innovation in pharmaceuticals was started during the pandemic, as a blessing in disguise. Though India has been the global pharma capital with affordable generic medicines for over a decade, in the pre-pandemic era, the Indian pharma industry was largely China-dependent for active pharmaceutical ingredients (API). The strictest lockdown in China impacted API mobility to India, forcing it to become self-reliant in APIs and medical devices like PPE kits. India introduced a Production Linked Incentive (PLI) scheme for promotion of domestic manufacturing of drug intermediates and APIs. Today India continues to be the global pharma capital, but without being China-dependent. This initiative has seen a quantum jump from Rs 100 crore FY23 to Rs 1,250 crore allocation for FY24. This is really laudable and shows the government’s far-sightedness. However, details have yet to come out on how this amount will be utilised except the mention that dedicated multidisciplinary courses will be started for skilled manpower development for developing medical devices, futuristic medical technologies, high-end manufacturing and research.
It is unfortunate that we haven’t learnt lessons from the pandemic and especially from the worst part during the April-June 2021 quarter orchestrated by the Delta variant. It looks memories are short-lived despite very high morbidity and mortality during that period touching almost every Indian, mostly due to shortage of medical preparedness and infrastructure.
There has to be adequate focus on the areas that are crucial as well as where collateral damage has been caused: like despite the government’s commitment to end tuberculosis by 2025, we lost 500,000 lives to it in 2021, the same number as that of deaths due to Covid in three years; childhood immunisation; strengthening the public health system; maternal and child health; mental health; HIV elimination as we committed to the goal zero cases by 2030. Two major pandemics that are lurking—Hepatitis-B, which has 5% prevalence in India and is fully vaccine preventable with vaccine costing pittance, and Antimicrobial Resistance (AMR)—have no mention in the budget and needs prioritisation. The National Health Mission (NHM) that targets public health strengthening for grassroots is facing neglect. The Pradhan Mantri Jan Arogya Yojana (PMJAY) needs to be toned up.
With digitisation of health records gaining by 70%, we should aim at smart health cards that can store crucial non-confidential data on immunisation, AMR, allergies, health records to augment faster and better healthcare and avoid duplication of efforts and spending. When a person goes to any hospital admission, for bed, ICU, surgery or medical procedure, tests are repeated several times.
We must invest very highly in health if we really want to enjoy the fruits of India’s continuous upward stride globally to give credence to the well-proven fact that “only a healthy nation can be a wealthy nation”. I hope there will be intense debate on the health budget for FY24, without any political bickering and it will be pushed on the path to reach the desired 4% of GDP during the supplementary budget.
Dr Ishwar Gilada is Consultant in HIV in Infectious Diseases, President of AIDS Society of India, Secretary General of Organised Medicine Academic Guild-OMAG and Governing Council Member of International AIDS Society, gilada@usa.net, www.unisonmedicare.com