Health budget hides key funding cuts

Despite a Rs 10,290-crore increase for 2017-18, an analysis of the Union government’s health budget reveals that most of this money is not being spent on India’s health priorities, which, instead, now face funding cuts. Elimination of tropical diseases (kala azar, filariasis and leprosy) over two years; elimination of a vaccine-preventable disease (measles) by 2020; elimination of tuberculosis (TB) by 2025; and "significant reduction" of infant and maternal mortality by 2020 – these were some key proclamations related to health made by Union Finance Minister Arun Jaitley during his February 1 budget speech.

Proclamations during budget

• Elimination of tropical diseases (kala azar, filariasis and leprosy) over two years;
• Elimination of a vaccine-preventable disease (measles) by 2020;
• Elimination of tuberculosis (TB) by 2025; and
• Significant reduction of infant and maternal mortality by 2020

Given that India has an infant mortality rate (IMR) of 37 per 1,000 live births (higher than the average for 154 middle- and low-income countries), the world's highest TB burden (with 27 per cent of new cases), and accounts for 58 per cent of new leprosy cases detected globally, Jaitley appeared to address some of the country's most significant public-health concerns.

Some stark realities

• Infant mortality rate (IMR) of 37 per 1,000 live births
• IMR higher than average for 154 middle- and low-income countries
• World's highest TB burden (with 27 per cent of new cases) on India
• India accounts for 58 per cent of new leprosy cases detected globally

Adequate funding can lead to significant improvement in health systems and health status. But Jaitley's budget indicates inadequate allocations or funding cuts to his declared priorities. To eliminate measles, India will need to invest in stronger immunisation systems and social mobilisation. It is starting the first phase of a measles-rubella vaccine campaign to immunise 35 million children in 2017 and 410 million children over the next two years.

Has money been set aside to achieve these targets? It appears not. Funding for measles elimination cut To fund the measles campaign and eliminate measles, funding under RCH flexipool (for rural areas) and under NUHM (for urban areas) should have been higher than previous years. Instead, funding for the RCH flexi-pool has been cut 23 per cent, from Rs 5,932 crore in 2016-17 to Rs 4,566 crore in 2017-18. Similarly, funding for the National Health Mission, which aims to provide universal access to affordable and quality healthcare and funds both NRHM and NUHM, has been reduced by Rs 197 crore over a year.

India has 27 per cent of the world's new TB cases – one of its biggest infectious disease killers. As we said, the Union budget's NHRM head provides for healthcare in rural India. Within this budget head is a sub-head called "Flexible Pool for Communicable Diseases", which includes funding for the Revised National Tuberculosis Programme. Now, funding appears to have increased by Rs 87 crore over a year to 2017-18, but the revised budget estimates –drawn up after the budget is presented – reveals a drop of Rs 13 crore over 2016-17.

Can’t cover all expectant mothers
In the 2017-18 budget, funding for Indira Gandhi Matritva Sahyog Yojna (Maternal Benefit Scheme) has risen 226 per cent, from Rs 634 crore ($94.6 million) in 2016-17 to Rs 2,700 crore ($298 million) in 2017-18, but this allocation isn't enough to cover all expectant mothers.

The government itself had estimated that the annual requirement for this maternity benefit scheme – it provides iron and folic-acid supplements to pregnant women to prevent maternal anaemia, sepsis, low birth weight, and preterm birth – would be Rs 14,512 crore ($2.1 billion), according the report of the Standing Committee on Food, Consumer Affairs and Public Distribution (2012-13). So, the ministry plans to provide maternity benefits only to first-borns, leaving other children vulnerable.

So where is the additional money going? A major increase in allocation has been towards more medical colleges at district hospitals, an increase of Rs 2,855 crore, accounting for about 27 per cent of the Rs 10,290-crore rise in health funding.

AIIMS lack critical facilities
India does need more medical graduates, but increasing medical colleges will not be easy, considering that even premier institutes, such as branches of the All India Institute of Medical Sciences (AIIMS), in state capitals are struggling. For instance, five years after the first batch was admitted, AIIMS Bhopal does not yet have a blood bank and does not conduct surgeries, and important faculty positions are vacant.

That bring us to the other significant increase: Rs 1,525 crore more for Pradhan Mantri Swasthya Suraksha Yojna (the Prime Minister's Health Protection Scheme), which is supposed to set up new branches of AIIMS in the states. In addition to the 11 that exist, Jaitley announced setting up of two more AIIMS, in Jharkhand and Gujarat.

Instead of opening new institutes, and investing about eight per cent of the health budget (Rs 3,975 crore of Rs 47,352 crore) to do so, the government should ideally focus on making sure that the ones already opened are functioning.

Little funding for wellness centres
Another significant increase of about Rs 3,000 crore is under the "Health System Strengthening" subhead of NRHM. This is likely to be allocated to another pronouncement: Converting 1,50,000 health sub-centers nationwide into "health and wellness centres". Again, this is not a bad idea, since functional sub-centers can take primary healthcare closer to where people live. But with no plan for this transformation made available – not even how many will be converted this year – Rs 3,000 crore appears inadequate.

For example, even if 25 per cent of the increased allocation under this sub-head is to upgrade sub-centres, no more than Rs 60,000 would be spent per sub-centre. So, while the current budget's health proclamations are apt, the funding increases for issues of low health priority are unlikely to make a significant impact on the overall well-being of the people. (In arrangement with IndiaSpend.org, )

By Pavitra Mohan