By Ali Mehdi
In her speech, the finance minister referred to ‘health and wellbeing’ as the first of six pillars of her Budget proposals for 2021-22, and called for ‘taking a holistic approach to health’ focused on ‘strengthening three areas: Preventive, Curative, and Wellbeing’. The accompanying graphics present the ministerial/departmental breakup of the Budget for health and wellbeing. The MoHFW and DoDWS allocations also include their respective FC grants.
The 2008 Report of WHO’s Commission on Social Determinants of Health (CSDH) reinstated the importance of going beyond the traditional health sector and focusing on SDH to tackle premature deaths, poor health and ‘much of health inequity’. Long before that, during 1820s and 1830s, Louis-René Villermé, the French physician and early pioneer of social epidemiology, conducted a series of studies that demonstrated interlinkages between death rates among prisoners and their detention conditions.
In Britain, vast differences in life expectancy across occupational groups were reported by Edwin Chadwick in his 1842 ‘Report on the sanitary condition of the labouring population and on the means of its improvement’, which became the basis for Britain’s first Public Health Act in 1848. Friedrich Engels, too, outlined ‘evidence regarding higher mortality among poor houses in poor compared to ‘improved’ streets’ in ‘The condition of the working class in England’ (1845).
Given the long-standing general evidence regarding the importance of public health measures such as clean drinking water and sanitation as well as the more specific one—of India having a mortality rate of 18.6 (per 100,000 population) that is attributable to unsafe water, unsafe sanitation and lack of hygiene (The World Bank, 2016)—I think the FM has rightly increased the allocation for DoDWS by 346% (including the FC grants for water and sanitation) vis-à-vis 2020-21 (BE).
However, given the increase in nutritional deficiencies from 321 million prevalent cases in 1990 to 443 million in 2019—making India the highest contributor in the world (Global Burden of Disease)—and the recently released results of the fifth round of National Family Health Survey (NFHS-5, 2019-20) also highlighting an increase in malnutrition burden vis-à-vis NFHS-4 (2015-16), it is surprising the allocation for nutrition (which was already very low; Rs 3,700 crore, as per 2020-21 BE) was further decreased by 27% during 2021-22 (BE). This is despite the fact that ‘Reinvigorating Human Capital’ is the fourth pillar of the Budget. Well, health and nutrition have not been part of the human capital discourse in India, anyway!
Focusing on prevention is fine. But given India’s massive burden of premature deaths (5.4 million in 2019) and disability (142 million years lived with disability in 2019)—making India the world’s largest contributor since 1990, the first year for which internationally comparable data is available—a mere 10.2% increase in MoHFW’s budget (29.8% if we include FC grants for health) vis-à-vis 2020-21 (BE) is utterly insignificant, and belies the claims of the Budget as well as National Health Policy 2017, which calls for raising government health expenditure to 2.5% of GDP by 2025.
The same holds true for minuscule allocations to MoA, despite claims of favouring/promoting India’s ancient medicinal systems. The promotion and increased uptake of these systems, especially at the international level, are dependent on high-quality evidence of their efficacy, quality and, not least, safety. Such evidence cannot be generated with such low allocation. Traditional medicine companies also do not possess the resources to invest in R&D even as a fraction of what companies in modern medicine do. Faith and superstition alone cannot drive the growth of ancient medicines.
At the same time, prevention cannot be restricted to water and sanitation—not to talk of even more restrictive preventive health check packages that various corporate hospitals and labs have on offer, and for which an income tax deduction of Rs 5,000 is offered by the MoF. According to WHO’s CSDH, poor health/health inequity ‘is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’. Should we expect any announcements on such social, economic and political determinants of health?
The author leads the Health Policy Initiative at ICRIER and Health as Flourishing Initiative at IDF. Views are personal