By Ali Mehdi
Indian Union Budget 2021-22: The Union Budget will be presented today and there are widespread expectations that in the wake of the Covid-19 pandemic, health would be a top priority. India’s government health expenditure (GHE) has been historically low and lamented, standing at 0.96% in 2018, ranking India 165th out of 187 countries (The World Bank).
Health is a state subject, and one could argue that expecting too much from a ‘Union’ budget isn’t really appropriate. During 1990-91, GHE was largely state/Union Territory-led. Union GHE was merely 0.09% of GDP, that of the states/UTs was 0.94%. However, by 2004-05, the former rose to 0.29%, even as the latter got reduced to 0.69%. With introduction of the Union-led National Rural Health Mission (NRHM) in 2005—one of the aims of which was to reduce inter-state and inter-district disparities, with a special focus on 18 states—central contribution to GHE increased further.
In recent years, although the central share is said to be on the wane, it has remained around a third of GHE, while states/ Union Territories have taken care of remaining two-thirds. Given the international nature of the Covid-19 pandemic, the Centre, once again, has had to play a leading role. One could, therefore, argue that, at least, as far as international health threats and inter-state health disparities are concerned, the Centre should continue to play a leading role, including vis-à-vis financing.
In addition to incentivising states to fulfil their constitutional responsibility—and disincentivising its negligence—the Centre can, very importantly, lead them towards evidence-based health financing through its own budget. In my opinion, lack of evidence-based health financing and policymaking has been much more injurious to health in India than low budgetary allocations/expenditures. The accompanying graphic shows that five countries—two in our immediate neighbourhood—managed to achieve a better life expectancy than India despite a lower GDP and GHE per capita. More money does not always mean better health—the role of various determinants of health should be analysed and addressed. This also means that, in the spirit of the social determinants of health (SDH), we need to look beyond allocations/expenditures of the ministry of health & family welfare—that of other ministries with a potential impact (negative/positive) on health also needs to be taken into account.For evidence-based health budgeting and policymaking, the central and state/Union Territory governments will have to allocate significantly more resources towards research and surveillance than they do at the moment. During 2019-20, 0.1-0.2% of the resource envelop of the National Health Mission (NHM) was allocated to ‘Review, Research, Surveillance and Surveys’ (RRSS) in most states. What sort of evidence-based policymaking can one expect with such levels of allocation?
The outcome is a highly skewed health budget. For instance, between 2005-06 and 2015-16, 63.1% of NHM expenditure at the national level was under its reproductive and child health component, while 6.7% of deaths in the country were due to maternal and neonatal disorders during this period; 4.5% of the expenditure was for its communicable disease control programmes, while 26.8% of deaths were due to communicable diseases; and a paltry 1.4% of the expenditure was under non-communicable disease programmes, while non-communicable diseases were responsible for 55.6% of deaths in the country during this period.
Yet, despite all the focus and allocations for RCH, India continues to be the world’s leading contributor to child deaths since 1953 (the first year for which internationally comparable estimates are available), managing to become world’s second largest contributor to maternal deaths in 2008. Clearly, there is enough room for evidence-based financing, planning and implementation in India’s public health sector.
I hope the central government uses the time until its next budget to introduce mechanisms towards this end. This will not only help prevent avoidable mortality and morbidity, but rationalise resources that have become scarcer due to Covid-19.
Leads the Health Policy Initiative (HPI), ICRIER, and Health as Flourishing Initiative (HFI), Inclusive Development Foundation (IDF)