(Courtesy: Indian Express)
Perspective
Before scrutinizing the health portions of the budget it should be enlightening to traverse through some previous occurrences during 2021-2023 period. National Family Health Survey (NFHS) is the most reliable dataset before us regarding different aspects of health, family, economic differentials and so on. NFHS -5 survey had revealed that over 57 per cent of women and over 67 per cent of children suffer from anaemia in our country.
Prevalence of anaemia to such an extent cannot be dismissed as a mild problem or an isolated occurrence. Medical experts have pointed out that it is a major contributor to maternal and child mortality. It hinders growth and development in children, leading to long term implications for their health and well being. Anaemia also reduces resistance to infections among women and children. The impact on adolescent girls and pregnant women is a matter of grave concern. Was it a inconvenient for the government? For a government that believes in strong and ‘positive’ data, to work in tandem with its political campaign for electoral victories, the NFHS-5 had thrown up several data sets inconvenient for the government. For example, it showed that India was nowhere close to being open defecation free – a claim that this government, including the Prime Minister, Narendra Modi, often makes.
Nineteen percent of households do not use any toilet facility, meaning that they practice open defecation, the NFHS-5 had pointed out. There is not a single state or Union Territory, except for Lakshadweep, where 100% of the population has access to a toilet, it had said. The NFHS-5 had also showed that more than 40% households did not have access to clean cooking fuel – thus questioning the claims of success of the Ujjwala Yojana. It said in rural areas, more than half the population, 57%, does not have access to LPG or natural gas. As a result, the high-placed government termed it as “flawed”. The Economic Times (October 16, 2023) published it under the heading “No place in Modi government for independent voices: Congress on revocation of IIPS director’s suspension after he resigns”.
Truly speaking, NFHS dataset are collected and collated and prepared by International Institute for Population Sciences (IIPS) and does other such important exercises on the behalf of the Indian government. The IIPS comes under the Union health ministry. It is an autonomous organization of the Ministry of Health and Family Welfare of the Government of India (GOI). Moreover, it is an institute deemed to be university. However, IIPS produced the NFHS-5. In this report, as the prevalence of anaemia among Indian population in such a huge proportion that the GOI was “Unhappy With Data Sets” used and sacked its director K. S. James being the scapegoat. The news was broadly publicized in most of the national dailies. Interestingly, K. S. James is an internationally acclaimed scholar serving as the visiting fellow in various universities of the Netherlands, Australia, UK, France and the Harvard University.
Importantly, the Lancet (Global Health) in their study titled “Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1–19 years in India: a population-based study” (9 June 2021) reported, “These findings support the re-examination of WHO haemoglobin cutoffs to define anaemia. Our haemoglobin reference percentiles, derived from healthy participants in a large representative Indian survey, are suitable for national use in India. Substantial variations in the 5th percentile of haemoglobin values across the 1–19 years age range and between sexes argue against constructing common cutoffs in stratified age groups for convenience … In conclusion, on the basis of high-quality national data from a recent survey, this study provides contemporary age-specific and sex-specific haemoglobin reference centiles for children and adolescents aged 1–19 years, which are suitable for national use in India.”
Another esteemed journal PLoS published a report (September 6, 2023) titled “Is the burden of anaemia among Indian adolescent women increasing? Evidence from Indian Demographic and Health Surveys (2015–21)”. It noted – “The prevalence of anaemia among adolescent women in India increased from 54.2% (99% CI: 53.6–54.8) to 58.9% (99% CI: 58.3–59.5) over the study period (2015–16 to 2019–21). Among the 28 Indian states, 21 reported an increase in the prevalence of anaemia … In conclusion, the rise in anaemia prevalence among adolescent women in India suggests the need for targeted interventions to mitigate the burden of anaemia and enhance the overall health of this population.”
In another study (“Shooting shadows: India’s struggle to reduce the burden of anaemia”) published in the British Journal of Nutrition (6 April 2023) it was reported – “Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015–2016 and 2019–2021) is concerning to India’s public health system … The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples.”
The Budget Itself
Such definite and positive suggestions, no doubt, might have appeared much disturbing to the ruling party, especially at the international level. Following this, NFHS-6 was prepared sans “flawed data”. The inclusion of anaemia as an indicator was dropped. Against this perspective, we can do a brief survey of “health budget 2024”. The health sector received little traction this year too. For years, experts have suggested that the health budget should be at least 3 per cent of gross domestic product (GDP) and even the National Health Policy, 2017 put the target for increasing the budget to at least 2.5 per cent of GDP by 2025. The FM allocated only Rs 90,171 crores to the health sector for the crucial election year 2024-2025. The health allocation at 2.5 per cent should have been Rs 8,19,000 crores, given the projected GDP for 2024-25 of Rs 3,27,71,808 crores. At 40 per cent, the Union government’s contribution should have been Rs 3,27,718 crores.
Here we should take into account three basic considerations – (1) “clinical health” (treatment of individuals in public hospitals or private clinics and five-star corporate hospitals) and “public health” (the science of protecting and improving the health of people and their communities) should not be equated and primary health centres are the cornerstone of public health, (2) consequently, “curative” health should not be paired with “preventive” health – these two are philosophically, socially and epistemologically different categories, and finally, (3) whether to “vertical” health programs (like American model) or “horizontal” health programs (like many European countries and Cuba).
(Courtesy: India Today)
Coming to the materiality of this year’s budget, in the interim budget presented for the year 2024-25, Union finance minister Nirmala Sitharaman pitched for a ‘Viksit Bharat’ by 2047. However, in that imagination of a ‘developed India’, the budget allocation for the department of health and family welfare and the department of health research, and key nutrition programmes have dipped for the FY 2024-25 as compared to FY 2023-24 budget estimates, when adjusted for inflation. Against the allocation of Rs 86,175 crores (according to budget estimates) for the department of health and family welfare for FY 2023-24, the allocation for 2024-25 stood at Rs 87,656 crores. While this seems to be an increase in absolute numbers, when adjusted for inflation at even 5%, this is a decline of 3.17%. Thus, in real terms, the budget for the health and family welfare department has gone down. For FY 2024-25, the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) has been allocated Rs 2,400 crore as against the budget estimate of Rs 3,365 crores for the last financial year. This shows a decline of 33% even without taking into account the inflation.
The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) is a flagship scheme of India government. This also saw a decline in allocation as compared to budget estimates for last year. It has been allocated Rs 4,107 crores for FY 2024-25 as compared to Rs 4,200 crores last year.
One notable announcement was the encouragement of cervical cancer vaccination for girls aged 9-14. The Budget aims to streamline various maternal and child care schemes into a comprehensive program, with a focus on upgrading Anganwadi centres under “Saksham Anganwadi and Poshan 2.0” for improved nutrition delivery and early childhood care. The Finance Minister said that the government will launch a programme to promote cervical cancer vaccination among girls aged 9 to 14, which industry observers said augurs well for vaccine makers. But one may argue that vaccinating girls against cervical cancer, the launch of more medical colleges, and improved mother-and-child care plans, among others, may be seen as big positives for healthcare companies and MNCs.
There is a separate head in the budget document titled “Establishment Expenditure of New AIIMS”. “It provides for establishment expenditure of 22 new AIIMS located at different states,” the document says. Under this head too, the budget estimates for FY 2024-25 have declined to Rs 6,800 crores from Rs 6,835 crores (budget estimates) for the previous year. But, actually speaking, according to a parliamentary reply given last year, not one of the 16 institutes conceived from 2014 is fully functional yet.
The Indian Council of Medical Research (ICMR), which comes under the department of health research and is the most prominent research body for health and science, has been allocated Rs 2,432 crores for FY 2024-25 as against Rs 2,360 crores for last year. Again, while in absolute numbers, this seems to be an increase, but when adjusted for inflation for even 5%, it is a decline of 1.87%. The scheme (Poshan 2.0 for providing nutrition) has been allocated Rs 21,200 crores for FY 2024-25, an increase from Rs 20,554.31 crores (budget estimates) from previous financial year. However, when adjusted with inflation of 5%, this allocation is actually a decline of 1.77%.
One worrying feature is that The decline in budgeted expenditure for health with respect to the total budgeted expenditure of the central government is worrying; the health sector outlay has fallen over the years, from 2.66% in 2022–23 and 2.06% in 2023–24 to around 1.98% this year Additionally, considering the inflation rate of 5.69% in December 2023, health spending in real terms has decreased.
In fact, the budgeted expenditure for the two ministries is a meagre 0.27% of the GDP estimate for 2024–25. Following the devastating assault on primary health care during the COVID period we can only expect that public health programmes should be reinvigorated on the one hand, and revitalization of primary health care on the other. Is it the time to be bamboozled and befooled again?
খুব সুন্দর লেখা স্যার। খুব ভালোলাগল পড়ে ।