So many questions have been asked about the Union Budget for 2018-19. Let me ask one on the Central government’s expenditure.
What does the government spend and on what? In 2017-18, the government estimated that it will spen Rs 21,46,735 crore, but it will end up spending Rs 22,17,750 crore — an increase of Rs 71,015 crore How will it get the additional money? It will get it entirely from additional borrowing (Rs 48,309 crore that the government will borrow directly, and about Rs 37,000 crore from ONGC, which will borrow as a proxy of the government).
Borrow and Spend
On what head will the additional borrowing be spent? Rs 1,07, 371 crore will be the increase in revenue expenditure. Consequently, capital expenditure will be cut by Rs 36,356 crore.
That is a double whammy. The government is borrowing heavily to spend on the revenue account and, in order to find the money needed, it is cutting back on the capital account. Did a large share of the additional revenue expenditure go to ‘Health’ in 2017-18? Hardly (see table).
As can be seen, the increase in expenditure, on account of health, over the Budget estimates was only Rs 4,320 crore, a small fraction of the total additional expenditure of Rs 71,015 crore and an even smaller fraction of the additional revenue expenditure of Rs 1,07,371 crore.
Child Health Indicators
Let’s look at one part of healthcare: the state of child health and child nutrition in the country. I have looked at the data for 2005-06 to 2015-16.
* Sex ratio at birth, that is females per 1,000 male children, has improved marginally from 914 to 919. At the current rate of improvement it may take many decades to achieve full gender parity.
* Infant mortality rate has declined from 57 to 41. The world’s average is 30.5 and the world’s best is 2.
* Under-five mortality rate has declined from 74 to 50. The world’s average is 41 and the world’s best is 2.1.
* In 2015-16, only 62 per cent of children had been fully immunised.
* Among children below the age of five years, one out of two is anaemic; one out of three is underweight and stunted; and one out of five is wasted.
Because we have neglected child nutrition and child health, the quality of our human resources is poor. From economic growth to national security to technological progress to social harmony, everything depends upon the quality of human capital. Doctors have a great responsibility to nurture our human resources, especially our children, but doctors are so few. India has one doctor for 1,681 persons (2016 data) and one government doctor for 11,528 persons, against the World Health Organization’s norm of one doctor for 1,000 persons. We produce only 55,000 graduate doctors and 25,000 post-graduate doctors every year. Each doctor carries the burden of at least two doctors.
Our healthcare system is broadly divided into three categories: public/government hospitals, private for-profit hospitals and private not-for-profit hospitals. Because of lackadaisical administration, public hospitals (with notable exceptions like AIIMS-New Delhi, JIPMER-Puducherry and a few others) are seen as inefficient, turning away patients and refusing to take normal risks while treating a patient. Many taluk- and district-level hospitals have become just referral hospitals.
On the other hand, private for-profit hospitals (with notable exceptions) are seen as purely profit-driven that prescribe redundant tests, procedures and treatment and turn away poor patients.
Scheme without Money
Notwithstanding free public hospitals and availability of health insurance, nearly every patient bears, out of his/her pocket, a substantial cost of medical care. The rural population spent (2014 data), on an average, Rs 5,636 for hospitalised treatment in a public hospital and Rs 21,726 in a private hospital. In the case of urban population, the corresponding amounts were Rs 7,670 and Rs 32,375. This and other data give rise to the question whether India’s healthcare system is becoming more and more unequal?
It is in this background one must critically view the National Health Protection Scheme announced with great fanfare. It is not ‘the world’s largest government-funded health scheme’, it is the world’s largest unfunded government health jumla. A National Health Scheme was announced in the Budget for 2016-17 to cover, through insurance, about six crore families up to Rs 100,000. No scheme was approved or implemented, or money allocated, and it was given a quiet burial. Now, a larger scheme to cover 10 crore families upto Rs 500,000 has been announced, but not one rupee has been provided. Insurers have hinted that the premium at 1-3 per cent will amount to Rs 50,000-1,50,000 crore a year and they were not consulted before the Budget announcement. There is talk of states sharing 40 per cent of the cost, but states were not consulted before the announcement. Besides, many states have their own schemes with their own branding, and there is no reason to assume they will come on board the new scheme.
It is an insult to the people’s intelligence to announce a grand scheme without forethought or preparation or money in the last year of the term of the government. Having made the announcement, the government will spend its time and energies and human resources to breathe life into a dead-on-arrival idea. Meanwhile, the neglect of the health sector will continue.