For better impact, link allocations for health care to outcomes
The 2022-23 Union Budget allocated ₹86,000 crore for health care. Adding estimates for state allocations and out-of-pocket expenditure allocation for health care is over 2.5% of Gross Domestic Product (GDP). There will be much hand-wringing over this because many countries spend much more. For example, member-countries of the Organisation for Economic Co-operation (OECD) and Development and China spend around 7% of the GDP on health care.
The relationship between expenditure on health care and outcomes is neither linear nor 1:1. The United States, which spends the most on health care (18% of the GDP), should have the best health care outcomes. But it does not.
So how do we tailor India’s Budget to match the requirement? We need to get out of the mindset of setting targets that are a fraction of the GDP. The “how much” question must be secondary to the “what do we want to accomplish in terms of health outcomes?” question.
How do we come up with outcome measures? The 2021-22 outcome budget of the Union ministry of health and family welfare lists several salient measures for the Human Immunodeficiency Virus (HIV). For example, “the percentage of people living with HIV who know they have HIV” — the targeted outcome is 90%. Having such discrete and targetable outcome measures has contributed to the success in combating communicable diseases. We need to do the same for non-communicable diseases (NCDs).
In the case of NCDs, devising outcome measures, that can be tracked at scale, is difficult given the varied manifestations of these conditions. But more proximal measures can be used. Take hypertension as an example — we can have an outcome measure that tracks the percentage of hypertensives who know they have hypertension, or we can track the percentage of hypertensives receiving appropriate treatment or the percentage of treated hypertensives having blood pressures in the ideal range.
Making the health care budget salient to current needs is a self-evident priority. But this often gets derailed by the lack of coordination between central and state spending on health care.
India’s accomplishment in containing or wiping out infectious diseases was due to centrally led and coordinated mission-mode programmes. Such an approach must be considered for NCDs too. But before allocating funds to NCD missions, the means to measure and monitor outcomes must be in place.
Digitally-enabled collection and analysis of data in real-time can inform the budgeting process, making it evidence-based, cutting wasteful expenditure and improving efficiency.
The National Digital Health Mission (NDHM) is a move in the right direction. But it has to be more ambitious. The minuscule allocation of ₹200 crore indicates that the State has not taken seriously the potential for digital medicine to transform the landscape for health care. The availability of high-quality data from NDHM can be the keystone for supporting a rational demand-led budgeting process for health care in which allocations are linked to specifically targeted health outcomes.