Synergy at Last

THE ROLE OF the Ministry of Health and Family Welfare has over many years been seen as providing a mix of some preventive and many clinical care services. Many critics suggested that it should be renamed the Department of Illness Care, since health was not promoted as a positive attribute. The problem lay in the fact that many of the social, economic, environmental and commercial determinants of health lay in the policy and programme remit of other ministries. Their allocations were never counted under the budget head of health. The health ministry’s budget itself stagnated around a very low level of public financing, inadequate for delivering the needed health services with efficiency and equity. As India’s public expenditure on health, Centre and states combined, remained around 1 per cent of GDP for several decades, the perennially disappointing health budgets drew constant criticism for low ambition and allocation.
Finance Minister Nirmala Sitharaman decided to buck the trend this year with the remarkably adroit move of creating a health and wellbeing budgetary head, combining the allocation for the health systems, water and sanitation, nutrition and reduction of air pollution. This not only enabled her to project a holistic vision of health (with preventive, curative and promotive services) but also claim an increase of 137 per cent in the health budget. Even though the health ministry’s overall budget rose only by 11 per cent, the complementarity provided by higher allocations to other health-friendly programmes made this combination a strategic move.

Water and sanitation, essential for protecting health, saw a threefold increase in allocation. Nutrition programmes, which faced serious challenges due to Covid-19 lockdown and restricted mobility, had difficulty in delivering the benefits at anganwadi centres and schools. Heads under which funds remained untapped saw a reduced allocation this year, though it would have been preferable to maintain the thrust on combating childhood undernutrition through home delivery. Merger of pre-existing nutrition programmes has seen the birth of Poshan 2.0 in the Budget. With budgetary support for reducing air pollution and improving urban public transport systems, the Budget signals support for a health-promoting environment.

The allocation to the health ministry’s programmes has been below expectations. The National Health Mission saw a rise of 9.6 per cent, though the need to energise rural comprehensive primary healthcare and awaken the slumbering urban health mission demands more resources. Allocation for the Pradhan Mantri Jan Arogya Yojana (PMJAY) stayed at last year’s level, since fund utilisation was low in the Covid-19 period as non-Covid care and claims fell sharply in hospitals. The Indian Council of Medical Research and Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) fared better with larger allocations.
The Covid-19 response featured strongly, through allocation of Rs 35,000 crore for vaccines and a new Centrally sponsored scheme to ramp up capacity for epidemic surveillance and control. The Pradhan Mantri AtmaNirbhar Swasth Bharat Yojana, operational over six years with a budget of Rs 64,180 crore, will strengthen disease surveillance at block, district and metropolitan levels and tighten screening at all monitored international entry points (air, sea and land). Public health labs in all districts and 3,382 block public health units in 11 states will strengthen pathogen and disease monitoring, while critical care units in 602 districts and 12 Central institutes will enable efficient case management. The National Centre for Disease Control and its five regional branches will be strengthened. A national institution will be established for One Health surveillance which tracks microbial migration from wildlife to veterinary and human populations. Further, nine biosafety level 3 laboratories would be set up, along with four regional institutes of virology.

In a happy coincidence for health, the recommendations of the 15th Finance Commission also arrived to provide guidance and money for strengthening public healthcare systems at Central and state levels. The commission recommended upgrading of both rural and urban primary healthcare, providing resources (unconditional grants of Rs 70,051 crore through local bodies and Rs 4,800 crore through state-specific grants). It allocated Rs 15,265 crore for critical care hospitals. The commission, whose recommendations on Centre-state division of tax revenues apply for the next five years, asked the states to raise the share of health in their annual budgets to at least 8 per cent by 2022. The commission asked for stronger regulation of the private sector and recommended the creation of an All India Medical and Health Service. It called for greater attention to non-communicable diseases and core public health functions such as disease surveillance.
The confluent impact of the health and wellness budget and the direction provided by the Finance Commission’s report create a path forward for strengthening the public health system. It enables decentralised local governance of health, provides the impetus for our journey towards a primary care-led universal health coverage and catalyses concerted action on the many determinants of health which lie outside the remit of the health ministry.

healthnutritionOpenomics 2021pollutionsanitationUnion Budget 2021