Envisioning health in 'amrit kaal': Hits and misses of Budget 2022

Outlays for some health programmes have increased, but no outlays for National Digital Health Ecosystem, new tele-mental health

Union Finance Minister Nirmala Sitharaman opened her Budget speech by expressing “empathy for those who had to bear adverse health and economic effects of the pandemic.” A central peg of her deliberations was “amrit kaal, the 25-year-long leadup to India@100” — underscoring three key imperatives: an all-inclusive welfare focus, promoting digital technology and reliance on a virtuous cycle of investments — all of which shall likely have a bearing on strengthening public health in the years ahead.

The overwhelming context of the Union Budget 2022 is, of course, the Covid-19 pandemic. The management of Covid-19 has been framed by its own set of metaphors and narratives. In India, it had a “laser-focus” on mitigating or containing the health emergency. The risk of treating the pandemic as a health emergency inevitably leads to framing a response framework that is too immediate, neglecting the slower, more gradual effects, damages and impacts. Recognising this as a “slow disaster” rather than an acute health emergency would possibly have led to greater recognition of the long, complex crisis.

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Two recent global reports underscore some of the challenges that contemporary public health faces: the World Inequality Report 2022 noting India is one of the most unequal countries with the top 10 per cent population’s share in the national income is 57 per cent, and the Lancet Commission on the Value of Death pointing to Indian figures of limitation of life support in intensive care unit at a low of 22–36 per cent. Deaths from infection, maternal and perinatal causes and malnutrition account for 26 per cent of deaths in India, in contrast to 4 per cent of deaths in China. Thus, ushering in 'amrit kaal' for the country in epidemiological transition has its task cut out.

The Economic Survey noted that revenues in 2021-22 have been marked by a strong rebound despite the fiscal deficit and government debt increasing in 2020-21 and capital spending pushing up in Q3 of 2020-21. The Budget for 2021-22 envisaged generation of ₹2.43 lakh crore of non-tax revenue, 16.8 per cent higher than 2020-21 PA. India’s overall score on the NITI Aayog SDG India Index and Dashboard improved to 66 in 2020-21 from 60 in 2019-20 and 57 in 2018-19. All these can expectedly lead to greater investment in social sector spending. Do we see the evidence of that - what are the hits and misses?

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The expenditure on ‘health’ includes expenditure on ‘medical and public health’, ‘family welfare’ and ‘water supply and sanitation’. The revised estimates in 2021-22 increased from an actual of ₹74,602 crore to a revised estimate of ₹85,915 crore (on account of increased pandemic spending); it has been marginally enhanced to ₹86,606 crores in 2022-23. The National Health Policy, 2017, envisages increasing the government’s (central and state) health expenditure to 2.5 per cent of the GDP by 2025. It increased incrementally from 1.4 per cent in 2014-15 to 2.66 per cent in 2018-19 and then in the pandemic years to 3.50 per cent (2020-21 revised estimates) and 4.72 per cent (2021-22 budget estimates). As a percentage of GDP, it remained at 1.3 to 1.4 per cent through 2014-15 to 2018-19, only to jump to 2.1 per cent in 2021-22 budget estimates. It will be closely watched if the trend in increase is sustained.

While health is a state subject, the Union government has played an increasingly important role through the National Health Mission, providing an umbrella for key disease control programmes as well as infrastructure strengthening. The pandemic brought in newer imperatives of central engagement with this sector. The building blocks of the health system include service delivery, well-performing health workforce, well-functioning health information system, medical products, vaccines and technologies, good health financing system and leadership and governance. The Union government is invested to various degrees in most of these.

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The India Covid-19 Emergency Response and Health System Preparedness Package was allocated ₹12,359 crore in 2021-22; this item seems to have been dropped in 2022-23. In the light of the pandemic, a new National Tele-Mental Health Programme has been announced, though its outlay was not mentioned. Variously referred to as telepsychiatry or e-mental health, information and communication technology supporting psychiatric services has long been considered as a potential option, particularly given the dearth in human resources and urban-rural, and primary-secondary-tertiary care divides.

Given the importance of human interaction and observation of human behaviour in this field, studies are divided regarding replacing conventional practitioner-patient relationships and satisfaction levels and outcomes. While there is a consensus that this is “worth the cost”, legal and ethical issues can be considerable. Given the ‘Mental Health Gap’, a more important imperative is an integration of mental health care in the existing system of primary healthcare. A sensitive model, therefore, is one where the primary care physician maintains responsibility for the patient and the specialist makes recommendations (through telepsychiatry) but does not directly manage or prescribe.

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As a ‘core scheme’, the outlay for the National Health Mission has marginally increased from ₹37,130 crore in 2021-22 to ₹37,800 crore in 2022-23. The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PMABHIM) is marked by a big jump from ₹585 crore in the previous year to ₹4,177 crore in 2022-23. It funds key activities (in a phased manner), including critical-care hospital blocks in 12 central institutions; 20 metropolitan surveillance units, five regional NCDCs [National Centre for Disease Control]; implementation of integrated health information platform (IHIP) in all states; strengthening disease surveillance and disaster and epidemic preparedness, and pandemic research and platforms for 'One Health'.

The outlay for the Pradhan Mantri Swasthya Suraksha Yojana has increased from ₹7,000 crore in 2021-22 to ₹10,000 crore in 2022-23. This scheme focuses on tertiary healthcare and medical education — new All India Institutes for Medical Sciences (AIIMS) and upgrading existing medical colleges. Insurance schemes, such as the Pradhan Mantri Jan Aarogya Yojana, have received significant attention too.

As a part of the Ayushman Bharat Digital Mission (ABDM), the finance minister announced that the National Digital Health Ecosystem will be rolled out to facilitate digital registries of health providers and health facilities, unique health identity, consent framework, and universal access to health facilities. Like the tele-mental health, no allocation was announced, though.

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As is well known, non-communicable diseases are a significant challenge, accounting for nearly two-thirds of the mortality at present. The adverse outcomes in terms of deaths and complications in the Covid-19 context highlighted the challenges more than ever. One would have hoped for more direct budgetary interventions for the ongoing National Multisectoral Action Plan for Prevention and Control of Common NCDs. Similarly, the country is committed to the World Health Organization (WHO)’s Rehabilitation 2030 Initiative to strengthen rehabilitation as an essential health service and crucial for achieving universal health coverage. Disability and rehabilitative services did not find any mention. The same can be said of other emerging areas like palliative care.

One can sincerely aspire that the overall 'amrit kaal' imperatives will reinforce and strengthen the markers of ‘access’ and ‘coverage’ — broadening the range of benefits to which citizens are entitled; extending access to these health goods and services to wider population groups; and, providing citizens with social protection against untoward financial and social consequences of health care. Both Union and state governments bear responsibility for securing the health and well-being of all citizens, the political idea that led the WHO to promote Health For All.

(Dr Rajib Dasgupta is Chairperson at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH

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