Booster shot elusive

Chandrakant Lahariya
Epidemiologist & Health Systems Expert

IN the Union Budget for the financial year 2022-23, the Department of Health and Family Welfare under the Ministry of Health and Family Welfare (MoHFW) has received an allocation of Rs 83,000 crore as per the budget estimates (BE). This allocation is a 15% increase over the Rs 71,239 crore allocated in budget estimates for the financial year 2021-22, almost similar to the revised estimates (RE) of Rs 82,920 crore. In addition, the Department of Health Research has received 3,200 crore, an increase over Rs 2,663 crore in BE and Rs 3,080 crore in RE. The allocation for the Ministry of Ayush is Rs 3,050 crore, which is almost similar to the budget estimates in the financial year 2021-22.

In the related sector, the Department of Pharmaceuticals has witnessed a major increase in allocation from Rs 470 crore to Rs 2,244 crore as per budget estimates. A majority, nearly 95% of the increase (Rs 2,157 crore), has been for a new line-item budget of Production Linked Incentive (PLI) schemes, including bulk drugs and medical devices parks. However, the allocation for Jan Aushadhi scheme, which aims to provide low-cost generic medicines, has remained stagnant.

In terms of new health services related initiatives, an open platform for rolling out the National Digital Health Ecosystem has been announced. The other initiative announced is a ‘National Tele-Mental Health Programme’ with the aim of delivering mental health counselling and care services. This will be achieved through 23 tele-health centres and coordinated by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, and the International Institute of Information Technology-Bangalore (IIIT-B) will provide the technology support.

Has health allocation really increased? One of the ways to objectively assess the allocation is to examine the allocation as the proportion of total expenditure. For the health sector, it has declined to 2.2%, slightly lower than the revised estimates for last year; however, marginally greater than the budget estimates. But when it comes to increasing the health sector funding to achieve the National Health Policy (NHP) 2017 target of government spending on health to 2.5% of GDP, this is clearly insufficient to achieve the policy goal.

Considering that the overall funding envelope has remained almost unchanged, there are changes in budget heads and placing money differently. Many component-wise sub-headings under the National Health Mission (NHM) have been merged, except the budget sub-headings for tertiary care programmes and human resources for health and medical education. There is an allocation of Rs 5,845 crore under the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PMABHIM), the scheme which was launched in September 2021. This allocation has been counted as part of NHM, as well as part of the budget for the Department of Health Research, and will be spent on bio-security preparedness and strengthening pandemic research as well as for ‘One Health’. Therefore, while there is some increase in the overall allocation under the sub-heading of NHM, allocation for older activities however has been reduced. The National Digital Health Mission (NDHM) has received Rs 200 crore. As part of the infrastructure push, there is a nearly 70% increase in capital expenditure from Rs 3,813 crore (revised estimate 2021-22) to Rs 5,632 crore (budget estimate 2022-23).

The Union Budget for 2021-22 was clearly focused on the pandemic. In the last budget, the linkage with other social sectors — nutrition, water supply and sanitation — the social determinants of health — was explicitly mentioned, which could have been retained. Similarly, a low expenditure on Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in the financial year 2021-22, specially when many people suffered financial hardships due to Covid-19 health services and hospitalisation, is telling that even though AB-PMJAY cards have been issued, the scheme might not be reaching the people who need them the most. Then, though the second Covid-19 health package was announced by the government in July 2021, the utilisation funds remained low, even after six months.

The current budget identifies a few problems such as the mental health burden, need for more medical human resources, strengthening disease surveillance and One Health approach. The tele-mental health programme apparently emanates from the right diagnosis of increased burden of mental health issues; however, it has not received an additional allocation. An explicit focus on ensuring better services such as management of post and long-Covid health conditions is clearly missing. The allocation for Covid-19 vaccines, which was Rs 39,000 crore in the financial year 2021-22, has been reduced to Rs 5,000 crore.

What is the way forward? First, one can hope that if and when required, the health sector will be given liberal, sufficient and a greater allocation in the revised estimates. Second, two-thirds of the government spending on health in India comes from the state budgets. However, states in India continue to under invest in health. The National Health Policy of 2017 proposed 8% of state government expenditure on health; however, nearly all states spend around 5% of state expenditure. The state government allocation for health has changed only marginally in the last two decades. It is time that an institutional mechanism for a regular review of the state health budget is established. One possible platform for such review could be meetings of the Central Council of Health and Family Welfare, which itself needs to be made regular.

The allocation for the health sector in the Union Budget for 2022-23, once adjusted for GDP growth, inflation rate and population growth, would be less than what was allocated in the pre-pandemic period. And that is where the problem lies. Especially, when India is still in the middle of the third wave of the pandemic, front-loading (of the health sector) has to be approached rather than tightening the purse-strings. 

#BUDGET #union budget