Can Budget 2016-17 breathe life into the public health system?

Per a report by the Planning Commission, India’s burden of water borne diseases remains grossly underestimated. The improvements in access to drinking water has not been matched by a proportionate decline in deaths and illnesses from waterborne diseases. It adds that poor water quality and the lack of adequate disposal of human, animal, and household wastes are contributing to waterborne diseases.

On the whole, public health in India leaves much to be desired. What are the asks from the standpoint of public health from this budget? What is hampering the functioning of the public health system and eroding its credibility? What sort of budgetary provision should be there for free medicines and diagnostics at all public healthcare facilities? Is there a need to fill up the vacancies in frontline health service providers? Why is it that the Indian Public Health Standards--which are less than optimal--are far from being reached?

A National Convention on the Union Budget 2015-16 by the Ministry of Finance at New Delhi dealt with these issues. Jan Swasthya Abhiyaan’s (India circle of the Peoples Health Movement) submission at the convention held on January 12, 2016 set down the budget asks related to the sector.

Public health spending needs to be upped

The Centre must immediately assure that its health sector spending is at least 50 percent of the total public health spending of the country. The states today--including Central grants--spend about Rs. 125000 crore, and if the Centre matches this with Rs.125000 crores then the total public health expenditure would jump to Rs.250000 crore from the present Rs. 150000 crore, becoming nearly 2 percent of the GDP. This first step must be taken if we have to achieve the Twelfth Plan target of 2.5 percent of GDP for public health expenditure. This is very much achievable immediately if the political will to recognise healthcare as a right exists. A benchmark of Rs.3000 per capita for healthcare at 2015 prices is the minimum amount needed to run a good public health system. States like Mizoram, Sikkim, Puducherry and Goa have already reached this target and are hence able to provide robust public health services.

Frontline provider recruitments (doctors, specialists, nurses, paramedics) are not keeping pace with the requirements. Even the Indian Public Health Standards, which are less than optimal, are far from being reached. Huge vacancies of doctors and specialists across the country hamper the functioning of the public health system and erode its credibility. To save and reclaim the public health system, all vacancies should be filled immediately as per Indian Public Health norms. To make this possible, appropriate budgetary allocations must be made. Further, to get doctors to work in the public health system, compulsory public service for 2 to 3 years must be instituted and their license to practice and their access to Post Graduate education should be linked to such public service. India produces 50000 allopathic and an equal number of non-allopathic doctors every year, so there are enough human resources for deployment in public service.

Projected share of centre-state health expenditure (2011-2022); Data source: High Level Expert Group Report on Universal Health Coverage for India, Planning Commission of India, 2011

Centre should honour Twelfth Plan commitment

The Centre must honour the Twelfth Plan commitment for free medicines and diagnostics at all public health facilities. Medicines constitute over two-thirds of out of pocket spending by households and this is a huge burden often leading to pauperisation. The budget allocations to fulfill this must be done. Presently, governments spend an estimated Rs. 5000 crore on medicines and this needs to be more than doubled.

New health policy should be passed

The new health policy, which is based on the High Level Expert Group recommendations, must be tabled in Parliament and made public. The attempts to scuttle it by the Niti Ayog, which seems to favour an insurance based and privatised health care system, must be put to an end. Healthcare needs to be recognised as a fundamental right and for this the National Health Bill must be finalised and passed. Also all user fees in the public health system must be immediately abolished.

Public health delivery system should function optimally

Budgetary allocations within health and for that matter any service delivery system should be done on a cost-based system so that the delivery system can function optimally. For instance, if a Primary Health Centre needs to deliver good services as per international public health system norms then the present budget of around Rs. 25 to 30 lakh per Primary Health Centre is grossly inadequate. We need at least Rs. 125 lakhs at current prices for a Primary Health Centre (and Rs. 200 lakhs including subcentres) that caters to 30000 population.

Civil society needs to be involved in health planning

The National Health Mission has a great opportunity of participatory engagement in health planning and budgeting through the Programme Implementation Plans (PIP). The PIP formulation in most places is a clerical exercise and hence needs to be pushed to involve larger civil society so that need or demand based budgeting and planning happens. Adequate budget to make such PIP formulation possible must be done.

While the Community Based Planning and Monitoring of Health Services (CBMP) process had been piloted in ten states, it is now functioning robustly only in Maharashtra. The impact of CBMP in Maharashtra is huge in terms of improved service delivery and so it needs to be extended across the country.

Public subsidy should provide social benefits

There are a large number of private hospitals registered under the Trust and Society’s Act as non-profits and others who have received direct subsidies like free or cheap land etc., with a provision to provide some proportion of services for free. The laws mandate that they provide 10 to 20 percent of services and beds free to poor patients. Since this is not monitored effectively, private hospitals do not honour such commitments and this public subsidy in the form of tax expenditures does not return any social benefits. This despite cases in the Delhi and Mumbai High Courts, which have issued orders to implement this provision effectively. Effective usage of this subsidy for the poor must be assured.

Need to measure up to the Sustainable Development Goals on the public health front

India failed to measure up to the Millenium Development Goals on the health front. With the new Sustainable Development Goals in place, the commitment to achieving these goals is dependent on effective strengthening of maternal and child health services on the one hand and effective delivery of treatment for communicable diseases like tuberculosis, malaria and HIV/AIDS treatment and prevention on the other. Adequate budgetary commitments for these must be made urgently.

The full submission by Jan Swasthya Abhiyaan is attached below.