Many hoped for Budget 2016 to be a renewed opportunity for the implementation of universal health coverage. These hopes had been fuelled by the rumblings from the ruling party about a universal health assurance plan and rumours of a significant increase in the financial allocation to the health sector. The actual budget made for sobering reading; in terms of its meagre allocation and lack of detail, this was surely an anaemic budget.
More disappointingly, I fear it will fail in achieving its most important stated goal of addressing catastrophic health expenditure.
Although the increase in the total allocation to the health sector represents an increase of 14 per cent from the previous year, this is only because of the significant cut in last year’s budget and, in real terms, is even less than what was allocated in 2014-15. This allocation will do little to improve India’s abysmal global ranking on public expenditure on health. The specific allocations to the National Health Mission, the flagship programme for the public healthcare delivery system, represent an insignificant change, and possibly even a reduction, from the previous year. It is notable that this amount is less than that committed for the recapitalisation of public-sector banks; in effect, the government has put yet more money into banks that have performed badly than on fixing the public healthcare system, which is witnessing a steady haemorrhage of the population to the private sector. It is perplexing, then, how this budget is expected to address the goal of reducing catastrophic health expenditure, which the finance minister rightly asserted was “the single most important cause of unforeseen out-of-pocket expenditure which pushes lakhs of households below the poverty line every year”.
Apart from the low investment in the public healthcare system, there are other troubling facts, or lack of them, which indicate the prescription of the budget will not cut the burden of catastrophic health expenditure. First, the beefed-up health insurance scheme needs to cover out-patient expenditure, not least on drugs and diagnostics, as these account for the major share of out-of-pocket health expenditure. In the absence of a structural reform of the health insurance scheme, one must assume it will continue to only insure in-patient care. Second, there needs to be a strengthening of the mechanism to hold the private sector accountable or else even the increased insurance cover will simply be swallowed up into the bottomless pit of irrational and unethical medicine, led by unnecessary hospital admissions and procedures. This would end up as one more example of public money flowing to private hands without any efforts to reduce costs or ensure transparency. Finally, if the health insurance scheme only targets those who live below the poverty line, the significant impact of catastrophic health expenditure on the impoverishment of those who live above this arbitrary line would not be dented at all.
The budget disappoints in at least three other respects as well. First, in the context of the abysmal contribution of health research in India either to global science or to solve the vexing problems facing our healthcare system, the government has allocated just 2.9 per cent of its health budget to research. Apart from this allocation being far below what other middle-income countries invest in health research, this pittance points to a striking contrast from the government’s policy to “make in India” and promote science and innovation. It seems that all of these mantras are reserved for profit-making enterprises rather than social sectors, despite the fact that high-quality health research can, in fact, achieve both the goals of social advancement and scientific innovation.
Second, amidst the lack of detail on any element of health spending, one particular intervention merits specific mention: Dialysis for end-stage renal disease. While I applaud this, not least as my own mother’s dialysis has bled my family’s economic security, what is curious is why just this one procedure is fished out from the ocean of interventions for chronic diseases, including insulin for diabetes (the leading cause of end-stage renal disease), or why the critically important investments needed to prevent these chronic diseases are not even mentioned.
My third grudge is that, yet again, beedis, the most widely used tobacco product in India, now well recognised as being just as deadly, if not more, as ordinary cigarettes, escape taxation. One commentator suggested this was to protect lakhs of workers in the beedi industry and I wondered how this might square with the loss of income consequent to the deaths of lakhs of those who consume this deadly product. The failure to hike taxes on the high-sugar food industry whose products include cola beverages, even though their association with diabetes and obesity is now well documented, remains perplexing. Instead, it seems the government is enthusiastic to fund the expensive dialysis that is needed as a result of the consumption of these products.
So, yet another year goes by when we have squandered an opportunity to address one of India’s most shameful truths: A country enjoying high levels of economic growth, producing large numbers of health professionals and volumes of cheap drugs, and boasting amazing ingenuity for creative innovations to address health problems at low-cost, also has the dubious distinction of being one of the most regressive healthcare systems of all middle-income countries. While universal health coverage has been a mantra for several years, no government has yet taken the firm steps needed, either in terms of adequate financing or re-designing the architecture of the healthcare system. We are back to hoping that next year turns out to be a better one for India’s health.