Economic Survey: Opportunity to Reorient Health Policies Wasted?

The Economic Survey 2020-21 document begins with the words “O Lord, Keep me not in Unreality, but make me go towards the Reality…” However, it seems that the government is still far away from seeing the reality.

While the Survey does try to articulate the problems that the Indian healthcare sector is facing, there is hardly any change in the policy orientation. In terms of budgetary allocation targets, the ruling dispensation has been high on rhetoric since the past few years, but its promises have not translated into reality. 

In the last year’s budget (2020-21), the Union government’s allocations for health had gone down from 0.33% to 0.31% of the Gross Domestic Product (GDP). The government boasts of bringing in the National Health Policy 2017, which promises increasing public health spending to 2.5% of the GDP by 2025. But this would require the government to actually increase the allocation for health every year by at least 30%. 

In the last budget, which was presented while some pockets across the world had already been hit by the pandemic, the total budget allocation for the health sector was increased from the previous year only by a meagre Rs 2,768 crore which, in real terms, was a decline of 4.3%. While the Survey asserts that the emphasis on the National Health Mission should continue, in the 2020-21, budget allocation under NHM was reduced by Rs 390 crore nominally, which, when adjusted for inflation, meant a 7% decline.

In a controversial claim, the Survey correlates Covid-19 cases and deaths with per capita government health expenditure and asserts that “Better healthcare infrastructure is no insurance against communicable disease”. However, the experience over the past one year has clearly shown that it was because of the inadequate and poor public health infrastructure in India that the response to the pandemic was abysmal. Most of the public health system was redirected towards combating Covid-19. As a result of this, patients with other ailments such as tuberculosis, cancer, etc. suffered grave hardships and maternal and child health services were badly hit. 

For a communicable disease such as TB, India accounts for about 26% of the global TB burden. WHO Global Tuberculosis Report 2020 states that “the Covid-19 pandemic threatens to reverse recent progress in reducing the global burden of TB disease”. It has also reported that there were large drops in the reported number of people diagnosed with TB between January and June 2020 ranging between 25%-30% and reallocation of human, financial and other resources from TB to the Covid-19 response. In India, too, there were reports of diagnosis machines being diverted to Covid-19 services. 

The insurance scheme under Ayushman Bharat, the PM Jan Arogya Yojana (PMJAY), continues to be high on the government’s priority list, despite the fact that there was a 51% decline in average weekly claim volume during the 10-week lockdown period (March 25 to June 2) compared to the 12 weeks that preceded lockdown. It is difficult to comprehend why a scheme, which failed to deliver during a public health emergency and essentially acts to transfer public money to the private sector, is being vigorously promoted by the government. 

Even during a nationwide public health emergency, the private sector has failed to cater to the people, and rather, has maintained its usurious tendency. In the past one year, a number of cases have emerged where the private hospitals have charged Covid patients exorbitant amounts, even flouting the price caps at times, and have even denied treatment.  

Also read: Before Budget: Revenues Crash, Debt Mounts – But People Still Deprived

The onslaught of the pandemic has established that the need to strengthen the public health system is indispensable. One of the key elements required is the enhancement of public investment in health. Some states have been trying to prioritise health, but the central government also must walk the talk and do its bit to increase the allocation for the health sector to at least 2.5%-3% of the GDP. 

The Economic Survey uses NFHS 4 and 5 data as evidence for ‘before and after’ comparison of PMJAY’s impact. PMJAY was officially launched in September 2018 and it is highly unlikely that the NFHS data can capture this impact. PMJAY, which is a government-funded scheme to cover secondary and tertiary level inpatient expenses for poor families, essentially promotes earnings for private hospitals. 

In terms of nutrition parameters, the NFHS 5 has, in fact, brought out an alarming situation. Observations from the report show that out of the 17 states, some states have one-third to nearly half of young children (up to 5 years of age) suffering from symptoms of chronic lack of healthy food: low weight, stunting and wasting. Around half to over three-fourth of children, and one-third to three-fourth of women in the reproductive age (15-49 years) suffer from anaemia. The Survey does not discuss these issues though. 

The health workers, who were hailed as warriors, had to face tremendous hardships during the Covid-19 lockdown. Due to the lack of protective equipment, they had to work in unsafe conditions. On raising their demands they had to face gag orders and even suspensions in some cases. However, there has been a lack of efforts on the policy front to ameliorate their condition. Taking the norm of the prescribed 1:3 doctor-nurse ratio, the studies based on the 68th round concluded that there is a shortfall of nearly 11 lakh doctors and 35 lakh nurses and midwives.

The frontline health providers – ASHAs and Aanganwadi workers – have been demanding the status of a worker and assurance of a minimum wage. Their role during the Covid-19 period has been exemplary, but they are still being treated as health volunteers and are paid meagrely.

If one looks at the budget for health research, it accounts for just 3% of the total MoHFW budget. Moreover, there has been underutilisation of resources under some of the programmes such as surveillance for Zoonotic and other neglected tropical diseases. In order to deal with any outbreak, it is important that a futuristic preparedness is undertaken and for this, there needs to be investment in research. 

The Covid-19 experience has also exposed the ill-preparedness of the government on account of medicines and equipment. In the past few years, the government has put many crucial public sector companies on strategic sale. However, in a recent report, a parliamentary panel has recommended that the pharma industry should be categorised as a "strategic sector", highlighting the need for strong indigenous pharma companies, calling for necessary action. 

In terms of offering solutions to improve the health sector in India, the Economic Survey is unimaginative and only harps on PMJAY as being the panacea of all ills. The Economic Survey is a classic case whereby data and statistics have been used to promote a particular narrative devoid of ground reality. The pandemic had given an opportunity to reorient the health policy towards strengthening public provisioning of healthcare and ensuring an equitable and affordable access to health for all. It only remains to be seen tomorrow what the Union Budget 2021-22 has to offer, though looking at the Economic Survey, the indications do not appear to be encouraging. 

Also read: Economic Survey 2021: Government’s Focus on Free Market for Healthcare?