By Abinash Dash
Capabilities of health systems around the world have been put to test by Covid-19. In India, cases have largely been confined to the metropolitan cities and urban areas; district-wise data till April 2020 shows that nearly one-third of positive cases are from four cities of Mumbai, Ahmedabad, Indore, and Pune. Though containing the spread in cities is a priority; the broader strategy should be to prevent the spread in rural areas, which could soon see cases explode.
The government’s effort is visible in terms of India’s preparedness to deal with the crisis by increasing the number of Covid-19 testing labs from a few labs to 511 labs (362 government and 149 private labs), mass production of N-95 mask and personal protective equipment (PPE) kit.
However, the spread of Covid-19 has shown some gaps in India’s health infrastructure preparedness. This crisis is an opportunity to plug these gaps in our health infrastructure, especially in rural areas. India has only 0.7 hospital beds per 1,000 population as compared to Brazil’s 2.2, China’s 4.2, Russia’s 8.2, United States’ 2.9 and Japan’s 13.4, and the world’s average of 2.7. Similarly, specialist surgical staff per one lakh population—a proxy for handling complicated procedures—is 6.8, as compared to the world average of 30.5.
Building health infrastructure requires adequate investment. WHO’s global health expenditure data shows that India’s current health expenditure, as a percentage of GDP, is 3.5%. This quite is low, compared to Brazil’s 9%, South Africa’s 8%, Russia’s 5%, and China’s 5%. And, India’s public health expenditure, Centre and state combined, is a meagre 1.3% of GDP. As such, India’s out-of-pocket expenditure in the current health expenditure, at 62%, is the highest among BRICS countries (Russia 40%, China 36% %, Brazil 27%, and South Africa 8%).
Additionally, in the Centre’s budgetary allocation the health sector received 2.3% of the total expenditure and is budgeted at 2.2% for FY21. Further, budgetary allocation of National Health Mission (NHM), Centre’s flagship health mission, has remained stagnant and declined marginally in FY21 (BE).
Strengthening the NHM, especially its rural component, i.e., National Rural Health Mission (NRHM) is crucial as rural poor rely primarily on public health care that comprises of sub-centres (SC) and primary health centres (PHC) for immediate health needs, and community health centres (CHC) and district hospitals are opted for in case of complicated procedures and specialist care. An SC is the first point of contact for seeking public health care that provides preventive care; a PHC is the first point of contact with a qualified doctor; CHC provides specialist care, including AYUSH care.
By 2022, 1.5 lakh health & wellness centres (HWC) are to be created by transforming existing SCs and PHCs. As per the latest Rural Health Statistics (2018-19), even including these HWCs, there is a 23% shortage of SCs and 28% for PHCs. Further, there is a shortfall of surgeons (85.6%), obstetricians & gynaecologists (75%), physicians (87.2%), and paediatricians (79.9%). Overall, there was a shortfall of 81.8% specialists at CHCs in 2019, against the Indian Public Health Standards. The situation of rural health care becomes acute when this shortage of health specialists gets compounded by absenteeism, poor maintenance of buildings, and unavailability of universal healthcare insurance.
According to the NSO survey (75th round), only 14% of the rural and 19% of the urban population had their health expenditure covered, of which, 13% of rural and 9% of the urban population are covered by government-sponsored health insurance. As such, most Indians are vulnerable to unexpected health care expenses.
Ayushman Bharat, targeted to cover approximately 50 crore beneficiaries, addresses this issue to some extent by providing a health cover of Rs 5 lakh per family for secondary and tertiary care hospitalization. However, the effectiveness of the scheme depends critically on increasing the quantity and improving the quality of health infrastructure in rural areas, as the private sector is unwilling to set up hospitals in these areas and provide procedures at the government prescribed rates.
Atmanirbhar Bharat initiative, in its last tranche, announced key health sector reforms such as increasing investment in public health and better preparedness for future pandemics. Public health expenditure and investment in health & wellness centres are set to increase. Setting up infectious disease hospital blocks in every district, integrated public health labs in every district, and health labs in every block and public health unit to manage pandemics in the future were announced. The financing for this, partly, is to come from the viability gap funding for which the Centre has earmarked of Rs 8,100 crores in its stimulus package. Though these reforms are well-intentioned, they lack clarity in terms of the specifics.
Making rural healthcare atmanirbhar should go beyond tackling exigencies. This would require not only building more health and wellness centres, but also procurement of medical equipment and filling up vacant specialists’ positions at various levels of the rural healthcare system. Making the Atmanirbhar initiative’s health component functional would require at least 2.5% of GDP to be spent on public health expenditure in a time-bound manner, as suggested in the National Health Policy 2017. Also, there is a need to implement the recommendations of Task Force on the National Investment Pipeline that has earmarked Rs 1.5 lakh crore for the health sector over FY20-25.
Incentivising private sector for setting up new hospitals in rural areas by providing single-window clearances for regulatory requirements and allocating land at concessional rates; increasing domestic usage of generic drugs; increasing budgetary support for the National Rural Health Mission (NRHM); regular social auditing of health infrastructure, and enhancing the incentive structure and ensuring timely payment to the Accredited Social Health Activist (ASHA) and other health workers would significantly improve rural health sector preparedness and make it atmanirbhar in true sense.
Joint director, department of economic affairs, Ministry of Finance