Yet another milestone has gone by in the economic history of this country; namely the budget. Readers will undoubtedly view the budget details through the prisms of their own personal interests. Changes in personal tax, corporate tax, the cost of living and so on will attract most attention; and healthcare as in the past, will attract little or none. The FM’s one-hour-twenty-seven-minute-long budget speech found little place for the term ‘health’ in the top nine priorities listed by the government. To compound matters, healthcare issues are acquiring ever-increasing complexities and dimensions. Surveys have shown that mental health problems have increased dramatically with the overuse of internet and social media, compounded by sedentary habits and unhealthy food, particularly amongst children. In adults the fallout is absenteeism and decreased productivity.
As per the Economic Survey 2022-23, the overall public health expenditure was at 1.6% of GDP in 2020-21 (actuals) and estimated at 2.1% of GDP in 2022-23. Dr Girdhar Gyani, Director General, Association of Healthcare Providers (AHPI), asked the government to increase budget allocation on health to at least 2.5% of GDP to meet its objective of having universal health coverage while flagging the World Health Organisation requirement of 3.5 beds per 1,000 people. In comparison, the United States allocated 17.9% of GDP to public health in 2022. Though India’s public health infrastructure and manpower have seen gradual improvement over recent years, significant shortages remain. As of 2022, there were 1,57,939 Sub-Centres (SCs), up from 1,52,326 in 2014. Primary Health Centres (PHCs) numbered 24,935, slightly down from 25,308 in 2014, while Community Health Centres (CHCs) increased to 5,502 from 5,335 in 2014. But shortfalls still persist. The World Health Organisation (WHO) recommends a doctor-to-population ratio of 1:1,000. However, India had a ratio of about 1:1,511 as of 2022. The number of doctors at PHCs rose to 30,644 in 2022 from 27,421 in 2014, yet many PHCs still operate without a full complement of medical staff. Total specialists at CHCs increased to 4,544 from 4,152 in 2014, but the requirement is higher, leading to gaps in specialised care. The shortfall in nursing staff, pharmacists and lab technicians continues. None of these matters received much attention in the budget. Over the last couple of years (2022-23, 2023-24, and now) there was a drop from 2.4% post Covid, to 1.9% of GDP, indicating that there is no focused agenda for the healthcare budget of the country.
There were some sops. The finance minister announced full exemption of customs duty on three key cancer drugs to provide relief to cancer patients. Quite apart from the criticism that the favoured drugs belong to one specific company, drugs for effective cancer treatment often cost Rs 1.5 lakh for 10 tablets. The Standing Committee (2022-23) on Health and Family Welfare noted that India ranks 176 out of 196 countries in terms of the percentage of current out of pocket health expenditure (OOPE). All imported lifesaving drugs not manufactured in India should have been given the benefit of exemption from customs duty and GST to reduce the burden on the common man. The GST exemption as well as tax relief should have been extended to health insurance premiums to reduce OOPE. The proposed changes in the basic customs duty for X-ray tubes and Flat panel detectors for use in medical X-ray machines are most welcome. However, there should have been more incentives for those entrepreneurs who propose to import advanced equipment if such imports would improve the delivery of advanced techniques in medical diagnosis and treatment.
It is regrettable that suggestions for budgetary allocation for healthcare have never featured in the planning commissions or Niti Aayog’s proceedings. Neither have any of the numerous professional bodies, (including the statutory ones) like the MCI (NMC), IMA, or APNH, ever presented a cohesive and concise demand for higher budgetary allocation backed by facts, and programmes. Opinions have been expressed on reducing OOPE in healthcare. Soumya Swaminathan as a co-author in a recent article states that “the multi-speciality general hospital that collates different specialities under one roof is too complex to scale up to meet the increased volumes in a UHC regime”. She states that for tertiary care, a focused factory model works better for quality and costs. Eye hospitals in India were quoted as an example. Her opinion is specifically quoted here, as she currently has an important function in the advisory group on health care. With all due respect to the lady and her illustrious past, such opinion ignores the ground realities. A hospital focused on joint replacement, for example, would involve patients with multiple medical problems; and the triple sword of Damocles hangs over the clinical establishment in the form of the CEA, CPA, and BNS 2023. Even the simplest of clinics, let alone speciality hospitals, must have facilities, including speciality personnel and equipment to tackle most medical eventualities and emergencies. For example, a patient admitted for a hip replacement, will need backup facilities for cardiac as well as pulmonary care. Without these backup facilities, the hospital may be denied its license, or sued for crores in the event of an unfortunate incident. Worse still, BNS section 106, subsection 1 may be imposed or God forbid, even Section 117 subsection 3 of BNS 2023. This defeats the whole purpose of the suggestion.
Healthcare is a vital component of any developed nation; but if the FM does not ‘put its money where its mouth is’ and puts some focus on healthcare, the day of the 5 trillion-dollar economy will remain a distant dream. Some experts are even suggesting that the time may have come for a separate healthcare budget like we used to have for railways. This being an ‘interim budget’, we sincerely hope for better things to come in future budgets for healthcare.
(The author is Past President of the IMA Goa State Branch, a founder member of VHAG, and a healthcare activist)
