The Union Budget 2021-2022 attempts to reimagine the health sector amidst the pandemic, it combines several budget heads to create a broad blueprint centered around strengthening Preventive, Curative and Wellbeing mechanisms in healthcare. The combined outlay for health and wellness announced by the Finance Minister was 2,23,846 Crore, a 137% hike over last year’s budget outlay of 94,452 Crore. The other key announcements for health include INR 64,180 crore over six years for the Pradhan Mantri Atmanirbhar Swasth Bharat Yojana (PMASBY) and INR 35,000 Crore for Covid19 vaccination.
The decision to combine allocations for determinants of health like water, sanitation, pollution control etc. with health and wellness highlights that the focus is more than just addressing immediate healthcare needs. This puts the emphasis on mitigating causal factors contributing to incidence of Non-Communicable Diseases while overcoming challenges presented due to the pandemic. More importantly it also warrants attention in bridging imbalances between states with respect to health infrastructure and manpower.
The focus of the budget this year has been to strengthen the public health system, thus the allocation under the PMASBY corresponds to a long-term vision in budgeting for healthcare. This is crucial and calls for better coordination between centre and states and requires larger framework to establish a system of Smart Health Governance.
Smart Health Governance system involves targeted investments for inclusive healthcare, which includes decentralised approach to building infrastructure and healthcare delivery. It also involves assessing determinants of health together under one bucket, something which has been highlighted in the Budget. Additionally, it also requires reforms that incorporate the use of technology to address shortage of healthcare manpower during this time.
Healthcare Delivery via Local Governments
Covid19 has taught us that quick action by grassroot communities and local governments (Gram Sabhas and Municipalities) is crucial to stemming adverse events like pandemics and epidemics. The XI and XII Schedule of the Indian Constitution lists Public Health and Sanitation as items to be delivered by local governments, it provides local bodies the autonomy to govern their own affairs. The 15th Finance Commission has acknowledged the importance of local bodies in addressing challenges to healthcare and supports a decentralised approach. It has also allocated INR 70,051 crore over the next 5 years to strengthen and plug the critical in primary healthcare in lieu of the pandemic. (Sector-wise breakup of grant is given below)
The Finance Commission’s allocation of funds to local bodies will help strengthen first response units across the country and provide an opportunity for the development of primary health centres at the grassroots development, which is crucial at a time when budgetary allocations have been inclined towards the private sector. It also provides an opportunity for different parastatal agencies to work together to enhance determinants of health and invest in innovative technologies that can help identify healthcare workers and increase resilience to withstand shocks to the health system in the long term. This is important because almost half the population in India depends on public health infrastructure while our national also stands among the top for Out-of-Pocket Health Expenditure, which as we all know is one of the contributing factors for poverty in India.
The Persistent Problem of Manpower Shortage
The acute shortage of healthcare workforce, including healthcare practitioners (HCPs) continues to be a persistent problem in India. To ensure the success of the Budget’s vision to set up 17,788 rural and 11,024 urban health and wellness centres, the government must address the manpower deficit. Numerous reports from the WHO and parliamentary standing committee on health and family welfare etc, have consistently raised this issue. The 15th Finance Commission Report has also highlighted the shortage of manpower and suggests reforms to address the shortage and the lopsided number of health workers in different states. According to the Ministry for Statistics & Programme Implementation report 2019, only Andhra Pradesh, Delhi and Tamil Nadu shows a balance between doctors and allied healthcare professionals. Moreover, with over 74% of graduate doctors living in urban areas, rural India overwhelmingly faces a severe dearth in the number of practitioners.
According to the Rural Health Survey, 2018-19, there is a shortfall of 85.6 per cent of surgeons, 75 per cent of obstetricians and gynaecologists, 87.2 per cent of physicians and 79.9 per cent of paediatricians. The Finance Commission has suggested setting up an All India Medical and Health Service, which would involve the Union Public Service Commission (UPSC) undertaking recruitment drives based on the requisition from each state. However, there needs to be clarity if this is purely for administrative purposes or if this is to offset shortage in different states.
Moreover, setting up an institution like the Medical and Health Services to address shortfall of practitioners of health workers will require a relook into existing regulations and that prevent doctors from practising in different states without registering in the respective medical councils.
The Finance Minister and the Economic Advisor have acknowledged the influence of telemedicine and Artificial Intelligence for healthcare delivery, which in reality depends on the rate of internet penetration in India. However, to ensure practitioners serve underserviced areas, the government must combine the use of technology and incentivise practitioners to serve in existing/proposed health centres and hospitals. Many medical graduates and professionals find it difficult to secure jobs with transparent wages and move to cities with the hope of securing better paying jobs. A technology platform that maps and lists vacancies with incentives can help bridge manpower asymmetry.
Therefore, in order to strengthen the Public Health system, the Government must enable a system to that ensures a decentralised approach to managing healthcare as recommended by the 15th Finance Commission. It should also address the important task of deficit manpower through reforms and utilisation of technology to make efficient use of existing manpower.