In this context, the Finance Minister in her budget speech announced whooping 2.23 lakh cr. allocation for 2021-22 ‘Health and Wellbeing’ expenditure. The Health and Wellbeing is one of the six pillars of 2021-22 budget proposal, and in popular connotation already started identifying as a much awaited financial vaccine for the India’s crumbling health sector. Thus it is needed to understand how this sixth pillar is actually going to transform the country’s health service system.
Apart from the conventional budget categories for health (explained in below paragraph), the Health and Wellbeing pillar includes the outlays of Drinking Water and Sanitation (60,030 cr.), Nutrition (2,700 cr.), COVID-19 Vaccine related special allocation as one-time expense (35,000 cr.), and Finance Commission’s grants (altogether 49,214 cr. for both health, and water and sanitation) to project the astonishing amount of 2, 23,846 lakh cr. It is not clear why the Finance Commission’s grant is shown as a part of budget framework as it is not centre’s resource. It is ideally meant for direct transfer by the Commission to urban and rural local bodies. From the point of fiscal federalism, it is tempting to see what the centre will do with these grants.
This allocation of 2.23 lakh cr., apparently, gives a programmatic framework of “[h]olistic approach to [h]ealth” to strengthen the “preventive and curative” parts of health care system alongside “[w]ellbeing”. It is of no doubt that benefits secured from the wider determinants of health (such as, safe drinking water, open defecation free villages, nutrition supplements especially for pregnant and lactating women, and children etcetera) do address the partial wellbeing of population and even help to avert many diseases. But can these determinants also operationally strengthen the health service delivery?
The 2021-22 health budget was supposed to address the age-old needs for facility infrastructure expansion, building skilled workforce, investing in medical research and technologies, reinforcing community-level health schemes and other system strengthening issues. The mere clubbing of health budget with other social sector overheads may financially endorse a holistic approach to health but can not deliver any booster dose to fix the structural problem of low public financing in Indian health sector. For 2021-22, the overall health budget of the Department of Health and Family Welfare (including AYUSH – Indian Systems of Medicine and Health Research) is decreased in absolute term by nearly INR 8349 cr. from last year (from 85251 cr. in 2020 – 21, RE- Revised Estimates, to 76902 cr. in 2021-22). This is approximately 2.2 % of the Total Budget compared to the 2.5 % of 2020-21 Revised Estimates.
The government’s much publicised flagship programme, i.e. Ayushman Bharat (PMJAY – Pradhan Mantri Jan Arogya Yojana and HWC – Health and Wellness Centre) has not seen much increment. The HWC component (implemented under the programme of National Health Mission in both rural and urban areas) gets a meek increase by 300 cr. (from 1600 cr. in 2020-21 expenditure budget to 1900 cr. in 2021-22). However, the budget outlays for the insurance/assurance based PMJAY scheme remains (6400 cr.) same in 2021-22 in comparison to the original expenditure budget of 2020-21. Importantly, unlike HWC the effect of pandemic did cut the PMJAY budget outlay in size (3100 cr. in 2020-21 Revised Estimates). The cause may be attributed to the access related problem by the beneficiaries in availing cashless hospitalisation services under PMJAY during the lockdown period and the threat from the virus infection.
In contrast, the widespread infection of corona virus finally enhanced the capital outlay on medical and public health after almost three years. It had been falling steadily from actual 3048 cr. (2017 – 18) to 2341cr. (2018 – 19) to 1640 cr. (2019 – 20). The pandemic made the government to ramp up its infrastructure for medical and public health services by readjusting the allocation to 4166 cr. (Revised Estimates) from its initial earmark of 996 cr. (Budget Estimates) in 2020-21. Though, the expenditure budget is again scaled down to 2434 cr. in 2021-22 for capital outlay on medical and public health.
Similar to last few years, 2021-22 budget again confirms that the National Health Mission (NHM) has been severely underfunded because of PMJAY. The NHM is known as a mainstay for sharp decrease in maternal and infant mortality, and increasing institutional delivery. The limitation of fund for NHM has been adversely affecting on the allocation for Reproductive and Child Health (RCH) services including immunisation, Communicable Diseases (CD), such as Tuberculosis, Malaria, Diarrhoea etcetera, and also Non Communicable Diseases (NCD) for last three years. The excessive focus on purchasing care (mostly from private sector) under PMJAY and overall stagnation in health budget have withheld the much needed expansion of NHM, after excluding HWC, from actual 34659 cr. (2019 – 20) to 35144 cr. (2020-21 Revised Estimates) to 36575 cr. (2021-22 Budget Estimates). Ironically, the 2021-22 health budget was most expected to rejuvenate the NHM for energising public service delivery. Instead of increased financial allocation, the 2021-22 health budget choose to go for internal redistribution at this time of epoch.
Despite all, there is a proposal for system strengthening in addition to the present NHM provisions. The new centrally sponsored scheme (namely, the PM AtmaNirbhar Swasth Bharat Yojana) shall have an outlay of about 64,180 cr. over a period of six-year to upscale the capacities of primary, secondary, and tertiary care facilities, strengthen existing health institutions, and also build new institutions for research, screening, detection and treatment of prevalent and emerging diseases. Though all these are at the announcement stage with no reflection in 2021-22 budget document.