The recently-announced health Budget was a ‘mixed bag’, and the government could have introduced special provisions for groups such as migrant workers, public health expert and epidemiologist Dr Chandrakant Lahariya said in an interview to Firstpost.

Lahariya, however, said that the Budget has made a good start by clubbing health with wellness —especially water, sanitation and pollution. The document also brings ‘social determinants of health to the forefront’, he remarked.

Lahariya has closely analysed India’s fight against the COVID-19 pandemic, with a focus on areas in which health systems can be strengthened. He recently co-authored a book titled Till We Win along with the director of AIIMS Randeep Guleria and well-known virologist Gagandeep Kang.

This year, the health and well-being component of the Budget naturally assumed particular significance as it came against the backdrop of the COVID-19 pandemic and an unprecedented economic crisis. Union health minister  Harsh Vardhan said the outlay for health increased this year by 137 percent, and asserted that the government has taken health and well-being to the ‘centre stage’ of India’s governance.

In this context, Lahariya offered his views on the hits and misses in the healthcare Budget, and what the government’s roadmap for the sector should be like. Edited excerpts:

On the whole, what is your view on the allocation for healthcare in the Union Budget?

This year’s Union budget was an unprecedented opportunity to guide the transformation of India’s health systems. However, at best, it has ended up as a mixed bag.

In terms of financial allocations to the ‘core health sector’, everyone had high expectations. There were many legitimate reasons for this. Firstly, soon after the start of COVID-19 pandemic, political leaders were united in the view that India (both at the level of the Centre and the states) needs to strengthen health systems. Political leaders had acknowledged the challenge of underfunded health systems and had called for augmenting resources. Secondly, the country’s third national health policy, released in 2017 (NHP-2017) recommended increasing government funding for health to the tune of 2.5 percent of the gross domestic product (GDP). The 15th Finance Commission and the Economic Survey 2020-21 also endorsed this recommendation.

The allocation to the health ministry for 2021-22 has increased by nearly 10 percent if we compare last year’s Budget Estimates with those from this year. However, if we compare the Revised Estimates of 2020-21 with the Budget Estimates of 2021-22, we see a decrease of 11 percent.

The government has also allocated Rs 13,192 crore as a Finance Commission grant for health.

However, if we go by the recommendations of the 15th Finance Commission, this grant will go to local governance bodies. This allocation is part of a Rs 70,000 crore grant from the Finance Commission. It will help urban local bodies and panchayat to strengthen primary care and public health. This is indeed a good start. The fact that this grant will go on for five years means that there will be reasonable continuity. This is important, as local governance bodies have not invested enough on health despite being empowered by the 73rd and 74th amendments to the Constitution.

Primary health infrastructure is weaker in cities as compared to rural areas. The involvement of panchayats in health services has a lot of potentials, as we have seen in states like Kerala.

Some argue that the Finance Commission grants are not part of the Centre’s allocation for health, as the grants ultimately go to local bodies. However, if we count government expenditure as a whole (Union and states combined), it effectively means an increase in allocation.

Further, though the Centre has not formally announced that it will cover the cost of COVID-19 vaccination, the allocation seems to indicate so. Indeed, that is the right thing to do.

I view some aspects of the health Budget as positive developments. One, health and wellness has been listed as the first of six pillars of ‘Atmanirbhar Bharat’. This may be symbolic, but in pandemic times, that is where health should be- first in the priority list.

Second, clubbing health with wellness — specifically water, sanitation and air pollution — is a good step. These, along with nutrition and many other factors, impact health outcomes and are termed as social determinants of health (SDHs). Nearly half of the health outcomes are dependent upon improving SDHs. The Budget has acknowledged the need for investing in these. It has given a much broader approach to health through curative, preventive and wellness components.

Thirdly, the PM-Atmanibhar Swasth Bharat Yojana (PMANSBY), though small in scale in its current form, aims to strengthen various functions associated with health systems. It complements the National Health Mission and the Ayushman Bharat programme. It focuses on strengthening urban primary health centres, which have lagged behind in spite of eight years of implementation of the National Urban Health Mission in the country.

This time, Budget heads such as drinking water, sanitation and nutrition are included in the allocation for health and well-being, which was  not the case earlier. In this context, could you give a perspective on how significant the Budget increase is?

From a service delivery perspective, clubbing these aspects together is a good idea. However, while interpreting the increase in allocation, we need to be a little careful.

In the National Health Policy 2017, the government committed to increasing core health spending to 2.5 percent of GDP. To achieve this target, an increase has to be made in the core health budget. One-time expenditure on heads such as COVID-19 vaccination is crucial. However, this doesn’t necessarily strengthen health systems. That will happen only when financial commitments are fulfilled over a reasonable period of time.

When we talk about how significant the increase in allocation is, there are a few unknowns. For example, PMANSBY has a budgetary allocation of Rs 64,180 crore over a period of six years.

However, these are not six equal instalments. Therefore, we don’t know how much will be allocated for FY 2021-22. We also don’t know whether it will come from existing Budget heads under the Department of Health and Family Welfare, or whether additional resources will be allocated for this scheme in the Revised Estimates.

Having said that, in any other year, an increased allocation of 10 percent in health budget would be accounted for through a GDP growth 6-8 percent and inflation of about 4 percent. However, a similar increase in outlay has different relevance in a year of GDP contraction.

According to you, what should be the government’s priorities in terms of financial allocations for healthcare? This would include aspects related to the pandemic as well as other healthcare challenges.

The PMANSBY is a step in the right direction, but the allocation for it could have been higher. The Finance Commission grant to elected local bodies is a good idea. However, the Union Budget needs to have stronger instruments than just centrally sponsored schemes, to nudge state governments to invest in health. Average state government investments on health continue to hover around 5 percent of their Budgets. This situation has changed only marginally in the last two decades. The National Health Policy, 15th Finance Commission and Economic Survey have all said that the figure should increase to 8 percent. If this target has to be achieved, a few interventions — in the form of nudges and incentives — need to be planned by states and the Union government together.

Further, local governance bodies must use Finance Commission grants in addition to what they already spend on health, and not instead of it. Mechanisms should be put in place to ensure this.

Mental health constitutes a major missed opportunity in this Budget. The pandemic has impacted the mental health of every citizen. The Union and state governments must rapidly strengthen mental health services through primary health centres. When else would be the right time to do so? After all, in the year that is now behind us, we had to deal with so many mental health challenges.

We know that the pandemic has widened inequities. We have witnessed the plight of migrant workers. A few special provisions for migrant workers, related to health as well as other issues, could have been considered.

Similarly, we have witnessed the role of health research in fighting diseases. The COVID-19 vaccines are an outcome of collaborative scientific research. Thus, the funding for health research could also have been boosted, as recognition of the work of scientific bodies.

Another learning from the pandemic is the need for stronger community engagement and participation for better health outcomes. The Finance Commission grants to urban and rural local bodies should be effectively used to this end. The delivery of healthcare interventions at the grassroots level must be done in a multi-sectoral manner, especially if we see health and wellness in conjunction. This will require collaboration and coordination between multiple agencies. Civil society organisations can become the glue to bind these stakeholders together, and can also act as an important accountability mechanism.

Do you believe India is allocating enough resources for healthcare as compared to other developing countries?

There is a consensus among policymakers that government spending on health in India is very insufficient, and is among the lowest in the world. It has increased only marginally in the last two decades, despite many policy commitments. In India, about 60 percent of the total health expenditure is borne by people from their own resources. This spending is termed as Out of Pocket Expenditure or OOPE. It is well known that when OOPE is high, people are pushed into poverty while accessing healthcare services. There is a global consensus that OOPE should be less than 20 percent. In Thailand, for example, it is around 10 percent.

The best way to reduce OOPE is to increase government spending on health. And that’s what is expected from both the Union and state governments.

Post the coronavirus outbreak, what changes do you believe the government should make to the country’s public health policy?

I think that waiting for the COVID-19 pandemic to get over is not a good idea. This is the moment when we, as a nation, should work towards a health system in which the poorest of the poor, in the remotest parts of the country, can access services without worrying about the payments.

Of late, the finance ministry has begun to hold dialogues with subject matter experts six to eight weeks before the Budget date. This is a good start, but it is not clear if such one-off interactions help enough. Such interactions need to be held on a more regular basis.

After the Budget as well, the finance ministry can formally engage with subject matter experts in various social sectors on how best to use the funds. These discussions can also deal with ways to better design and scale up interventions.

At present, there is a very interesting pattern of discourse and discussion around the Union Budget in general. A week before Budget day, subject matter experts share their wish lists for various sectors in newspaper articles. But by then, the ‘halwa ceremony’ (a tradition which marks the end of the Budget formulation process) is already done, and the document is in the printing stage somewhere in the basement of the finance ministry. Thus, the articles make for interesting reading but are unlikely to affect the contents of the Budget.

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