By K R Antony
With the worst phase of the Covid-19 pandemic seemingly over, finance minister Nirmala Sitharaman is busy stitching together an annual budget for India. Everybody is looking forward to the new proposals and promises in the budget for the health sector. Many lessons have been taught by the coronavirus on where her priorities should lie.
One undeniable truth is that the vulnerability of India’s public health system was exposed by the pandemic. The country neglected the poor and the marginalised for decades and paid the price for it. No one can deny that India’s public health system needs an immediate upgrade. The healthcare infrastructure of the country proved its relevance and essentiality despite all its shortcomings. The nation needs it and that learning must be clearly reflected in Budget 2021.
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The alternative option for ordinary citizens was the private sector that showed its true colours during the pandemic crisis. They ran away from the scene or closed their gates even for the lucrative tertiary care, surgeries and other profitable services. In any case, they were neither interested nor involved in primary healthcare or preventive medicine. Health promotion activities or immunisation activities were bequeathed to the public health system.
For out-patient consultations and admission for surgeries and procedures, common people utilised private sector to the extent of 65-70%. The dependence on private sector was because of easy availability and assumed quality of service with an unaffordable price tag. Many families got impoverished due to the expensive procedures while several others got into a debt trap.
There was a cumulative neglect in funding, staffing, infrastructural and technology upgradation of public health system, resulting in dismembering and annihilation of public health institutions, which from the British colonial era were providing yeomen services.
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If health is a basic human right under the constitutional guarantee of Right to life, the government, not private sector, should provide that health and services to sustain it. It must be a justiciable right. A welfare nation should not abdicate that responsibility to the private sector or entrust Insurance sector to manage it. Just paying the premium for insurance coverage for listed services, the government cannot absolve itself of the responsibility of providing basic health services to all citizens.
Right to health is not only an individual’s lookout, but also that of the state. Globally acclaimed universal healthcare cannot be achieved by relying on Insurance packages and roping in private sector. The private sector is so heterogenous and scattered in its presence and availability. During the pandemic crisis, private sector displayed its lack of standardisation, medical anarchy and uncontrolled exploitative pricing.
It is high time we invested more in public health and determinants of health like nutrition, water, sanitation and education. Realisation of a historical demand of minimum 3% of the GDP allocation for health sector must be this year’s working principle in budget formulation. We spent only 1.3 % in 2018-19 and less than that in 2019-20. That translates to an amount of Rs 1,969/- per capita expenditure. It was a total of Rs 56,226 crore in 2018-19 compared with the previous year’s Rs 50,281 crore.
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In the National Health Plan 2015, it was declared as a policy to spend 2.5% of the GDP in healthcare. At least we must allocate around Rs 80,000 crore for public health. Out of this chunk Rs 55-60,000 crore can be allocated for National Health Mission. That will be a challenge for the funds absorption capacity of NHM that needs a strong and professional project management team in every state.
Currently there are around 275,000 contractual workers who are essential to the project activities under NHM budget. Many consultants and technical hands appointed added value to the program implementation. It became the cornerstone for transforming health services as a mission instead of a departmental activity. That quality improvement led to client satisfaction and increased utilisation of services by the public health system.
A huge army of around 900,000 women, named ASHAs are working relentlessly in the country as part time voluntary workers. The term voluntary is a highly exploitative arrangement to overcome requirements under the prevailing labour laws.
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They were the back bone of the entire surveillance activity in the community, contact tracing, getting suspects tested, quarantine of the family members and isolation of clinically asymptomatic positives and reverse quarantine of the vulnerable and the elderly during the pandemic. If ASHAs are inevitable to run the health programme, be it so and pay them well. Consume required funds for that from the increased allocation.
Health and wellness centres
These are the newly branded face of health sector in the last couple of years, boosting its image among people as well as the confidence of the staff. In every state, it is making a difference. A retrained nurse, pharmacist or sector supervisor acting as community health officer is available 24×7 in rural areas for medical consultation, investigations, dispensing medicines and to provide first aid and emergency care. A mini hospital is functioning in the neighborhood. In Budget 2021, we need to allocate adequate funds to complete its infrastructural improvement and supplies.
District hospitals
There is an imminent need to upgrade the amenities and service provision of the apex hospital in every district. In districts without a government medical college or super specialty hospital, these are the institutions where serious Covid-19 cases got aggregated. They got choked beyond their capacity and the available staff were overstretched. We need more fund allocation for equipping and strengthening every district hospital in the country. ICUs in a district hospital should be expanded. The gap identification and its remedial measures will be crucial for an efficient public health system not only during disasters, but also during normal times.
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Free drugs and diagnostics
It was a progressive policy decision to provide free drugs and diagnostics across the country. Considerable progress has been made to have IT-enabled drugs and equipment procurement and supply system eliminating corruption and staggered replenishment of stocks in districts and below in public health institutions. Outsourcing or rate-contract based purchase of diagnostics from private sector should give way for an inhouse provision. It requires additional allocation of budget which must be reflected in the current one.
TB and malaria – unfinished public health agenda
One unpardonable mistake during the lockdown was the near closure of case detection and treatment of these two killer diseases. As it is, we were the largest contributor to the global burden of these two and there were many unfinished agenda of controlling and eliminating them. An Atmanirbhar Bharat has to find its own budget allocation to remove the shameful status on the endemicity of tuberculosis and malaria.
Urban public health system
Wealthy cities may not be healthy cities in the country. Mumbai, Delhi, Pune, Hyderabad and Kolkata proved that a weak public health system can make the life of urban poor miserable and equally dangerous to the middle and richer class.
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Migrant labourers are the least enumerated, accounted for and planned for builders of the economy. It is in the interest of everybody that the urban poor and migrant workers are cared for and their health protected. They contribute so much to the economy and GDP, and without them cities cannot function.
Slum area provision of basic services — water, sanitation and clean night shelter or temporary dwellings must be a priority action whether they are legalised or unauthorised squatters. Budget 2021 should allocate more funds for quality urban healthcare and services especially in slum areas.
Multi use community centers
During cyclones, floods, earthquakes and pandemics, people need these structures for relocation, for relief camps, for isolation or quarantine and for community meetings and social events. There are such structures constructed in many villages in Manipur state by the government. It is more relevant in coastal areas, mountainous regions and vast flood prone plains. We need to invest for this from any sectoral budget including health budget as it serves the needs of all sectors.
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Role of health insurance in public health
With the infusion of various government-sponsored schemes, there is a phenomenal growth in the health insurance market to more than Rs 30,000 crore. Till the government builds up a robust public health infrastructure, insurance-based purchase of secondary and tertiary healthcare from private sector may be continued, but with very stringent oversight against misuse and exploitation.
Expansion of National Health Protection Scheme from the current 10 crore households and 50 crore beneficiaries should not be at the expense of the existing public health institutions and slashing of budget allocation for RCH and, communicable / chronic diseases as happened in Budget 2020. The government must be concerned more about the health of citizens rather than that of insurance and healthcare companies. Hope Budget 2021 will reflect this preference in money terms.
(Dr K R Antony is a public health consultant based in Kochi and an independent monitor for the National Health Mission. Views are personal.)