India Budget 2011-12 – A Brief Comment

The 2011-12 budget overall shows that there is further compression in public spending. There is a southward trend in the budget with the estimates indicating only a 13% nominal increase over the previous year and a decline in the budget estimate as a proportion of the GDP by more than 1% point to14% of GDP. This is happening despite the real growth rate being over 8%. Similarly tax revenues of the Central budget have stagnated around 10% of GDP. The Centre has failed to net in increased revenues from the growing national income. And the present budget does not give any indication that the Tax:GDP ratio will move northwards. Unless the latter happens we cannot expect public spending, especially for the development and social sectors like rural development, health, education, welfare, housing etc.. to grow significantly. Today public spending on health is a mere 1% of GDP when WHO recommends that it should be atleast 5%. The government over the last six years has not been able to move towards its own target of 3% of GDP for health. The share of the Central government in public spending for health is a mere 0.25% of GDP when as per the UPA target it should be 40% of 3% of GDP that is 1.2% of GDP or Rs. 86,400 crores at today’s prices.

In contrast to that the Central Ministry of Health allocation is only Rs. 30456 crores (including grants to states), short by Rs. 55944 crores as per commitment of UPA government. Of the Rs 30456 crores, Rs. 1700 crores or 5.5% of the Health Ministry's budget goes to HIV AIDS, which has been accorded a status of a separate Dept in this year’s budget; Rs 771 crores goes to Health Research, mainly ICMR and its institutions and Rs. 1088 crores to AYUSH. The Health and Family Welfare department gets Rs 26897 crores of which Rs. 16140 crores goes to NRHM and Rs. 5435 crores goes to the Central Government Hospitals and Medical Colleges and further Rs. 653 crores goes for healthcare of Central government employees under CGHS - a whopping Rs. 3628 per Central government employee in sharp contrast to about Rs. 500 per capita which all state and the Central governments together spend on healthcare for its citizens

Under NRHM some of the key allocations are Rs. 1238 crores for the various National Disease Control Programs like TB, Vector borne diseases, blindness. leprosy etc., Rs 3378 crores for Family Welfare, Rs. 240 crores for RCH, Rs 511 crores for routine immunisation and Rs. 664 crores for polio, and the Mission and RCH Flexipool gets Rs. 8776 crores. In addition NRHM also gets funds of Rs. 1784 crores under the NE special program and Rs. 247 crores under AYUSH.

So what does the above tell us. The overall spending on healthcare by government is certainly very low when we consider global standards. As a consequence the out of pocket burden for citizens, especially so of the bottom two quintiles is huge - about Rs. 3000 per capita. While within the Central budget the allocation to health ministry has increased by 21% over the previous year and gives the impression that health and other social sector programs are an important priority for the government. This is largely due to the political push under the flagship programs and is a good sign but when we look at actual expenditures then this optimism is belied. Actual spending in the social sectors like health and education are invariably 10-15% less than the budget estimates and often in the key programs like NRHM and Sarva Shiksha Abhiyan as also pointed out in the audits conducted by the CAG. This year for the first time the Central budget has included actual expenditure for 2009-10 and we see that for the Health Ministry the overall shortfall in expenditure as per the budget estimate was 8%, and 10% for the plan component of the budget, most of which goes as grants to state governments. However the surprise is (actual expenditures are still provisional) that NRHM shows an actual expenditure in excess of 17% (7% excess in plan expenditures), largely due to the RCH and immunisation programs and pumping in of non-plan resources (whopping increase from the Rs.72 crores in budget estimates to Rs. 1397 crores in actual expenditure) which certainly shows an increased commitment on part of the Central ministry of Health. Perhaps 2009-10 was the year for the consolidation of the NRHM program but this came as a cost to the medical care sector under the Ministry of Health, which means that public hospitals and teaching hospitals were neglected, their shortfall in expenditure being as much as 20%

To conclude, while the UPA government seems to be inclined towards strengthening the public health system by giving a larger weightage to the health sector in budgetary allocations, overall this is not enough because there is significant compression of overall public spending. The consequence is that this impacts public health spending and the neglect of the public health system continues.

UPA's Public Health Performance

UPA’s all flagship programs are under stress. During their previous tenure the UPA formulated their strategy and had 3 to 4 years for the various flagships to build their foundation. But we see that success has eluded them, especially in the social sector arena of health, education and welfare. The National Rural Health Mission attempted to do what the Minimum Needs Program did way back in the eighties. The MNP succeeded in creating the rural health infrastructure – the PHCs and subcentres - as per the 1981 National Health Policy to support the goal of Health For All by 2000 AD. This even pushed the public health spending upto 1.6% of GDP, the highest ever for the country. While the physical infrastructure was in place, the human resources, medicines, equipment etc were far from adequate and failed the strategy. And then we were subjected to SAP and the macroeconomics that followed spelled disaster for the social sectors, halving the public health spending from the MNP peak to a mere 0.8% of GDP. To stem this collapse of the public health system the NRHM was launched with a target of pushing public health spending to 2 to 3 percent of the GDP by making architectural corrections.

At the end of their first tenure the UPA managed to take public health spending barely to 1 percent of GDP, no where close to their target. The rural public health system continued to suffer from the same malaise as earlier – not enough doctors and nurses, inadequate medicine supplies, poor maintenance etc. What was worse is that the reasonably robust urban public health system also began to collapse with rapid private sector growth and expansion, including the support of private health insurance. Thus the inadequate public investment in health during the previous UPA regime actually led to the boom of private healthcare which had now jumped to 5.5% of GDP. Since private insurance covers barely 2% of the population, most of this expenditure is out-of-pocket indicating a huge burden on households who often had to sell assets or take loans for their hospitalization needs. Thus the UPA government failed to make any significant impact in the public health domain.

The failure is both political and bureaucratic because there is a complete lack of political will to push radical reforms or the architectural changes the NRHM strategy document talked about as well as the inadequate capacity of the bureaucracy to facilitate the structural changes. During the period of the UPA regime we saw in Thailand a major transformation where social insurance and increased public financing catapulted Thailand to the status of a universal access country assuring equitable access to basic healthcare for all. If Thailand could do it given a very similar historical trajectory to that of India then why can’t UPA facilitate the same for India? The answer lies in viewing the entire health system, both public and private, as a single system and creating a regulatory mechanism and a financing strategy of a single-payer instrument and to accommodate that under a single umbrella. Well the first 100 days of the second UPA regime does not show any inclination towards that end. Hence civil society has a long struggle to get the UPA on track to achieve the goals of universal access to basic healthcare.

Doctors, Nurses and Public Health System

Getting Doctors and Nurses to Work for the Public Health System
One major concern with the functioning of the public health system is availability of key functionaries, especially doctors and nurses. The question is not one of lack of production because that happens adequately with about 25000 each of doctors (allopathic alone, in addition about 20000 AYUSH doctors) and nurses being produced annually. Infact we produce enough to cater to the world and Indian doctors and nurses are in great demand all over the world – over 5000 doctors and 7000 nurses go abroad each year. But the public health system, both in rural and urban areas, is unable to attract the requisite human resources needed for running the public health system. This despite the fact that over 80% of such production happens with public resources.

It is time that the legislators of this country give serious attention to this shortage of human resources for the public health system if the National Rural Health Mission has to achieve any significant success. Apart from doctors and nurses the public health system also needs managers under the architectural corrections mandated by the NRHM.

Over the years various mechanisms have been tried but they have failed because there was no legal backing for them. Whatever was done was done on good faith which is in fact the corner stone of the medical profession. But we all know that ethics in medical practice is getting even more distant with gross commercialization of healthcare and good faith is no longer a value cherished by this profession. This makes the role of the lawmakers of the country even more critical.

It is very clear that the only way of meeting the shortages of human resources for public healthcare and other public services is by instituting legislation that mandates compulsory national/state public service of 3 to 5 years. Thus all medical and nursing graduates as well as management, engineering, accounting, general stream etc.. graduates must put in compulsory public service as a social return for the investment in them by the public exchequer. This will not only provide the public system with human resources but it will also instill social responsibility and ethics in the professionals.

A number of countries have national public service, either military and/or non-military, and it is time India put in place such a mechanism. We need a legislation on national public service for anyone attaining age 21 with immediate effect otherwise the economic growth and development will have little meaning as we will increasingly lose skills and resources to the developed world one way or another.

We can learn from different countries, some have general compulsory public service and some target specific professionals like doctors and nurses. Since there is already a historical debate on the health professionals doing some compulsory service like in rural areas we can begin with this profession through a national ordinance making public health service compulsory with immediate effect and gradually bring in the broader legislation for a national public service.

We urge Parliamentarians to consider this with urgency and bring this into effect in the winter session of Parliament. Since 25000 each doctors and nurses graduate each year and over 10000 specialists also, we can immediately fulfill all shortages faced by the public health system with one stroke of the pen. Doctors and nurses will agitate and resist but the State must show strong political will to realize the critical objectives of our Constitution of social justice and equity. Similarly management graduates, especially from the IIMs should be targeted as for them it would be a great opportunity to prove their skills in efficiently managing public systems before they learn to manipulate markets. The NRHM needs these management graduates as much as they need doctors and nurses. Let the public health system become the experimental ground for a national public service because with healthcare needs addressed, a healthy population is the best guarantee for economic and social development.

(Published in IMPF Newsletter Vol. 2 No. 3, Winter Session, 2007)

Making it Happen...

A large part of my career I have spent on working on this issue through research, trainings, campaigns, advocacy... This is a dream that I have nurtured since I go into the field of health way back in 1982 when I joined the Foundation for Research in Community Health. Under the then raging community health movement one was swayed by experimental alternatives and the NGO sector seemed to appear as a panacea to realizing this dream but a quick study of this sector made it very clear to us that some of the NGOs were in the business of charity and others were just in business, albeit with an alternate approach that atelast appeared to be progressive on the face of it. With further research into households and their expenditures on health care in 1987 it became crystal clear that healthcare was a business the way it was being run, whether run by the government, private sector or the NGOs. The need was to change this so that healthcare was reestablished as a public good, that is it was not left to the mercy o the markets. Thats the key essence of healthcare and only when we imbibe that will we be able to realize the dream of right to healtcare...
Actually I do not see it as a dream anymore. In fact that was the mistake.. How can right to healthcare be a dream? It has to be a reality!
Then some of us friends came together and set up Anusandhan Trust in 1992 and its first centre the Centre for Enquiry into Health and Allied Themes (CEHAT) with the objective of moving towards establishing right to healthcare. We pursued the same interests and tried to reach out to the larger world by expanding debate and dialogue on these issues, collaborating with many others who had joined this struggle. Through this emerged the Peoples Health Movement in 2000 and later its campaign on Right ot Healthcare. (see http://phmovement.org/ )
The PHM's campaign of Health For All Now and the right to healthcare while mobilzing communities and civil society has been collaborating with public agencies like the National Human Rights Commission and the National Rural Health Mission etc.. with an increasing hope of realizing the right to healthcare.
While this goal may still appear to be distant it is becoming increasingly desired by more and more people. The question is not whether this is possible but whether we want to make it possible... Resources are not really an issue. In one of my other posts Money for Right to Health I show that we do not have dearth of resources and that we can actually realize this with less than half of what we all spend on healthcare, mostly out of pocket and with very poor results. Thus if we make right to healthcare a reality then we will actually save resources that we spend wastefully on unregulated healthcare....