Largest health programme has little for India’s poor

Health is being hailed as the biggest winner of the Indian Budget 2018, but a cursory look at the numbers shows that there is nothing to celebrate as far as the health budget is concerned. In fact, the budget this year once again highlights the government’s complete lack of vision as far as ensuring ‘Health for All’ is concerned. The finance minister’s speech mentions two main interventions — health and wellness centres that “will bring healthcare system closer to the homes of people” and “a flagship National Health Protection Scheme to cover over ten crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage of up to five lakh rupees per family per year for secondary and tertiary care hospitalisation”.

The second aspect has made headlines as being something ‘revolutionary’ in healthcare. Neither of these is a new initiative, nor are these likely to improve access to healthcare or reduce out-of-pocket expenditure.

Given the noise being made around how much of a boost the health sector has been given, one is led into believing that there is a major increase in the budget. On the contrary, the allocation for the Department of Health and Family Welfare for 2018-19 is Rs52,800 crore, an increase of about 2.5 per cent from the revised estimate for 2017-18 which is Rs51,550.85 crore.

Therefore, in real terms and as a percentage of GDP, there is a decline in the health budget this year.

To achieve 1.5 lakh health and wellness centres, the finance minister has allocated a royal sum of Rs1,200 crore ‘for this flagship programme’. This comes to Rs80,000 per sub-centre — not enough to fill the gaps. Moreover, this is not a new initiative, as it featured in the 2017 budget speech as well. There have been no reports on the experience from this in the previous year, neither is it clear what this actually means.

Currently, sub-centres suffer from poor infrastructure, under-staffing and lack of equipment and medicines. One can safely assume that for a sub-centre to become a health and wellness centre, the least that could be expected is that these basic facilities and human resources are provided. It is hard to understand how this can be done with the meagre funds allocated.

Now, coming to the second announcement, which is the ‘world’s largest government-funded healthcare programme’. Here, as well, it should be remembered that in the budget speech of 2016 — by the same finance minister — a similar claim had been made. In 2016, it was announced that “the government will launch a new health protection scheme which will provide health cover up to rupees one lakh per family”. Two years on, the Rashtriya Swasthya Bima Yojana (RSBY) cover remains at Rs30,000 a year with the promise that this will now be increased to Rs5 lakh. The amount allocated for the RSBY in 2016-17, to give a cover of Rs1 lakh for one-third of the population, was Rs1,500 crore.

This never took off and less than Rs500 crore was spent. The budget also announces a change from 3 per cent education cess to 4 per cent ‘health and education cess’, and it is estimated that this would bring in an additional Rs11,000 crore. Even if we expect 25 per cent of this additional amount to come to the health sector, we should have seen an increase of Rs2,750 crore in the health budget. Rather, there has been an increase of only Rs1,250 crore this year. What this budget seems to be doing, therefore, is raise additional revenues from common people in the name of health expenditure for the poor, while enabling higher profits for the private healthcare sector. In this context, the surge in the share prices of healthcare and insurance companies is quite telling with regard to who the real beneficiaries of this scheme will be.

Experiences from across the world show that depending upon the private sector to deliver healthcare for all — based on health insurance to take care of the burden of out of pocket health expenditure — escalates overall healthcare costs, excludes many and distorts practices of ethical and appropriate care. Even when this government attempts to do anything for the health of people, it hopes to do this through the private sector and not by strengthening the public health system.

We also have enough evidence from India to show that an insurance-based strategy does not effectively address this problem of out-of-pocket expenditure. For primary care, the strategy is to depend on public services which are currently inadequate. This does not address the main issue of out-of-pocket

This budget is not about the largest health plan; it is about the country with the highest number of child and maternal deaths spending less than other countries

expenditure as in India, 67 per cent of all expenditure on health is out-ofpocket and of this, 63 per cent is on out-patient expenditure.

Focus on insurance instead of strengthening availability of public services allows the government on the one hand to get away with low allocations for health and, on the other, provides more opportunities for the private sector to make money out of poor people’s illness. The high burden of out-of-pocket expenditures (OoPE) on health in India has rightly been recognised by many as one of the main problems facing the people.

There are also a large number of academic articles, recommendations of government committees, the National Health Policy and so on which state that the expenditure on healthcare in India needs to be increased to at least 2.5 – 3 per cent of the GDP. Yet, year after year, we remain at around 1 per cent to 1.2 per cent of the GDP. The headlines have got it wrong — this budget is not about the world’s largest health protection plan – rather, it is about the country with the highest number of child and maternal deaths in the world spending less than almost all other countries in the world – a country where government after government has shown no commitment to the health of its citizens. —thewire.in Dipa Sinha teaches at School of Liberal Studies, Ambedkar University, Delhi