The unveiling of the Union Budget to the new parliament on July 23 continues the process initiated by the interim (pre-election) Budget presented in February. Political continuity in the government makes it likely that proposals made in the interim Budget will continue, amplified by additional elements identified on the basis of sectoral priorities and financial feasibility. Where will health feature in the financial architecture for India’s development, when we are no longer battling the Covid-19 pandemic but are shining the torch on a path to Viksit Bharat by 2047?
The interim Budget addressed the problem of cervical cancer and promised to “encourage” the vaccination of girls between nine and 14 years of age, with the human papilloma virus vaccine now being manufactured in India. This suggests that while such vaccination will not be mandatory, it will be supported by the government through a funded national programme. The Budget of July 2024 will need to elaborate on the financial resources earmarked for it. This programme was initiated in Punjab and Sikkim in 2016. The central government will now have to fund nationwide expansion. Since cervical cancer is the second most common cancer among Indian women, with 80,000 deaths reported in 2022, this programme is long overdue.
The interim Budget proposed to extend coverage under the Pradhan Mantri Jan Arogya Yojana (PMJAY) to Asha and Anganwadi workers. The government also recently announced that persons aged 70 years and above will be eligible for coverage under the PMJAY. The modalities for expanded coverage will probably be elucidated in the new Budget. There is also a concern regarding the “missing middle”. A large fraction of the population is presently not covered by government health insurance for low-income groups or private insurance purchased by high-income persons. The PMJAY may have mechanisms to provide access to uninsured persons through paid contributions.
Another announcement in the interim Budget was related to the U-WIN programme for managing universal immunisation across the country. Buoyed by the success of the COWIN digital management programme for countrywide immunisation with Covid vaccines, the U-WIN seeks to facilitate more extensive coverage by the universal immunisation programme. According to the most recent National Family Health Survey (NFHS-5), the country’s full immunisation coverage during 2019-21 was 76.1%. A well-designed and efficiently managed U-WIN should help us to achieve the target of universal immunisation.
What will attract most attention of health sector observers is the proposed total allocation for health and the specific programme and agency distribution within the health budget. Given the demographic shifts (larger population, increasing urbanisation, more elderly persons, and rising rates of chronic disease risk factors), the health burdens of non-communicable diseases — such as cardiovascular and cerebrovascular diseases, diabetes, cancers etc. — will demand more extensive health services that match needs across the country, as will mental health promotion and protection programmes. While there has been commendable progress in reducing infant, child, and maternal mortality rates, wide-ranging inter-state disparities in a number of key health indicators need attention and continued programme support. While strengthening our disease and risk factor surveillance apparatus, we need to invest in climate change-responsive and disaster-resilient healthcare systems, alongside efficient pandemic preparedness. These demand higher budgetary allocations.
The Covid-19 pandemic saw increased government spending on health during its peak. Looking beyond that unusual period, there has been a decline in allocation to health as a proportion of total budgetary outlay in recent Union Budgets. The share of health in “actual” government expenditure was 2.46% in 2019-20 and 1.86% in 2022-23. In the budgetary estimate of 2023-24, it was 2.06%. The “actual spend” is yet to be reported.
Within health expenditure, the share of the National Health Mission (NHM) declined from 52.48% to 42.83% in 2022-23. The budgetary estimate for NHM was 38.35% of the health budget in 2023-24. Since the NHM is responsible for improving rural and urban primary care, district hospital strengthening, and delivery of several vital national health programmes, the enfeeblement of NHM is a matter of concern. Will the Union Budget reverse this trend, especially since the urban health mission component of NHM is yet to pick up speed?
By adding more categories of beneficiaries, the PMJAY is likely have a raised allocation. Expansion of tele-health and other digitised health services will see increased funding of the Digital Health Mission. The Health Infrastructure Mission too will gain bugetary momentum.
With the government strongly committed to promote ayurveda and yoga, we may expect higher allocations to the Ayush ministry. With the success of an inactivated virus vaccine (Covaxin), produced under aegis of the Indian Council of Medical Research, health research would expect an increased investment. With an ambitious Heal in India programme already announced, medical tourism is likely to be incentivised.
Delivery of universal health care will need greater investments in developing a large, multi-layered, and multi-skilled health workforce. We need more doctors, nurses, and allied health professionals, not only for meeting the absolute shortages and distributional disparities within India, but also to meet global shortages. With a favourable demographic profile of a young population for the next three decades, India is aiming to become a global supplier of skilled healthcare professionals through its Heal By India programme. These call for greater investment in health professional education.
Allocations to water, sanitation, hygiene, nutrition, and pollution control have been rightly listed in recent Budgets as related to health. All of these will require increased budgetary allocations. With climate change advancing alarmingly, we must invest in developing climate-smart and climate-resilient health systems which can respond to the health assaults of climate change while reducing greenhouse gas emissions from health care facilities and their supply chains.
K Srinath Reddy, distinguished professor of public health and ex-president, Public Health Foundation of India
Views are personal