Minor Dissections

Indian Health Budget 2024

Jayanta Bhattacharya

Before scrutinising the health portions of the budget it should be enlightening to traverse through some previous occurrences during 2021-2023 period. National Family Health Survey (NFHS) is the most reliable data-set regarding different aspects of health, family, economic differentials and so on. NFHS-5 survey had revealed that over 57 percent of women and over 67 percent of children suffer from anaemia in the country. Prevalence of anaemia to such an extent cannot be dismissed as a mild problem or an isolated occurrence. Medical experts have pointed out that it is a major contributor to maternal and child mortality. It hinders growth and development in children, leading to long term implications for their health and well being. Anaemia also reduces resistance to infections among women and children. The impact on adolescent girls and pregnant women is a matter of grave concern. Was it an inconvenient for the government? For a government that believes in strong and ‘positive’ data, to work in tandem with its political campaign for electoral victories, the NFHS-5 had thrown up several data sets inconvenient for the government. For example, it showed that India was nowhere close to being open defecation free – a claim that this government, including the Prime Minister, NarendraModi, often makes. Nineteen percent of households do not use any toilet facility, meaning that they practise open defecation, the NFHS-5 had pointed out. There is not a single state or Union Territory, except for Lakshadweep, where 100% of the population has access to a toilet, it had said. The NFHS-5 had also showed that more than 40% households did not have access to clean cooking fuel – thus questioning the claims of success of the UjjwalaYojana. It said in rural areas, more than half the population, 57%, does not have access to LPG or natural gas. As a result, the high-placed government termed it as “flawed”. The Economic Times (October 16, 2023) published it under the heading “No place in Modi government for independent voices: Congress on revocation of IIPS director's suspension after he resigns”.

Truly speaking, NFHS data sets are collected and collated and prepared by International Institute for Population Sciences (IIPS) and does other such important exercises on the behalf of the Indian government. The IIPS comes under the Union health ministry. It is an autonomous organisation of the Ministry of Health and Family Welfare of the Government of India (GOI). Moreover, it is an institute deemed to be university. However, IIPS produced the NFHS-5. In this report, as the prevalence of anaemia among Indian population in such a huge proportion that the GOI was “Unhappy With Data Sets” used and sacked its director K S James being the scapegoat. The news was broadly publicised in most of the national dailies. Interestingly, K S James is an internationally acclaimed scholar serving as the visiting fellow in various universities of the Netherlands, Australia, UK, France and the Harvard University.

Importantly, the Lancet (Global Health) in their study titled “Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1–19 years in India: a population-based study” (9 June 2021) reported, “These findings support the re-examination of WHO haemoglobin cut offs to define anaemia. Our haemoglobin reference percentiles, derived from healthy participants in a large representative Indian survey, are suitable for national use in India. Substantial variations in the 5th percentile of haemoglobin values across the 1–19 years age range and between sexes argue against constructing common cut offs in stratified age groups for convenience ... In conclusion, on the basis of high-quality national data from a recent survey, this study provides contemporary age-specific and sex-specific haemoglobin reference centiles for children and adolescents aged 1–19 years, which are suitable for national use in India.”

Another esteemed journal PLoS published a report (September 6, 2023) titled “Is the burden of anaemia among Indian adolescent women increasing? Evidence from Indian Demographic and Health Surveys (2015–21)”. It noted – “The prevalence of anaemia among adolescent women in India increased from 54.2% (99% CI: 53.6–54.8) to 58.9% (99% CI: 58.3–59.5) over the study period (2015–16 to 2019–21). Among the 28 Indian states, 21 reported an increase in the prevalence of anaemia ... In conclusion, the rise in anaemia prevalence among adolescent women in India suggests the need for targeted interventions to mitigate the burden of anaemia and enhance the overall health of this population.”

In another study (“Shooting shadows: India’s struggle to reduce the burden of anaemia”) published in the British Journal of Nutrition (6 April 2023) it was reported – “Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015–2016 and 2019–2021) is concerning to India’s public health system ... The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples.”

The Budget Itself
Such definite and positive suggestions, no doubt, might have appeared much disturbing to the ruling party, especially at the international level. Following this, NFHS-6 was prepared sans “flawed data”. The inclusion of anaemia as an indicator was dropped. Against this perspective, one can do a brief survey of “health budget 2024”. The health sector received little traction this year too. For years, experts have suggested that the health budget should be at least 3 percent of gross domestic product (GDP) and even the National Health Policy, 2017 put the target for increasing the budget to at least 2.5 percent of GDP by 2025. The FM allocated only Rs 90,171 crore to the health sector for the crucial election year 2024-2025. The health allocation at 2.5 percent should have been Rs 8,19,000crore, given the projected GDP for 2024-25 of Rs 3,27,71,808 crore. At 40 percent, the Union government’s contribution should have been Rs 3,27,718crore.

Here one should take into account three basic considerations–
(1) “clinical health” (treatment of individuals in public hospitals or private clinics and five-star corporate hospitals) and “public health” (the science of protecting and improving the health of people and their communities) should not be equated and primary health centres are the cornerstone of public health, (2) consequently, “curative” health should not be paired with “preventive” health– these two are philosophically, socially and epistemologically different categories, and finally, (3) whether to “vertical” health programmes (like American model) or “horizontal” health programmes (like many European countries and Cuba).

Coming to the materiality of this year’s budget, in the interim budget presented for the year 2024-25, Union finance minister NirmalaSitharaman pitched for a ‘Viksit Bharat’ by 2047. However, in that imagination of a ‘developed India’, the budget allocation for the department of health and family welfare and the department of health research, and key nutrition progra-mmes have dipped for the FY 2024-25 as compared to FY 2023-24 budget estimates, when adjusted for inflation. Against the allocation of Rs 86,175 crore (according to budget estimates) for the department of health and family welfare for FY 2023-24, the allocation for 2024-25 stood at Rs 87,656 crore. While this seems to be an increase in absolute numbers, when adjusted for inflation at even 5%, this is a decline of 3.17%. Thus, in real terms, the budget for the health and family welfare department has gone down. For FY 2024-25, the Pradhan MantriSwasthyaSurakshaYojana (PMSSY) has been allocated Rs 2,400 crore as against the budget estimate of Rs 3,365 crore for the last financial year. This essays a decline of 33% even without taking into account the inflation. The Pradhan MantriAyushman Bharat Health Infrastructure Mission (PM-ABHIM) is a flagship scheme of India government. This also saw a decline in allocation as compared to budget estimates for last year. It has been allocated Rs 4,107 crore for FY 2024-25 as compared to Rs 4,200 crore last year.

There is a separate head in the budget document titled “Establishment Expenditure of New AIIMS”. “It provides for establishment expenditure of 22 new AIIMS located at different states”, the document says. Under this head too, the budget estimates for FY 2024-25 have declined to Rs 6,800 crore from Rs 6,835 crore (budget estimates) for the previous year. But, actually speaking, according to a parliamentary reply given last year, not one of the 16 institutes conceived from 2014 is fully functional yet. The Indian Council of Medical Research (ICMR), which comes under the department of health research and is the most prominent research body for health and science, has been allocated Rs 2,432 crore for FY 2024-25 as against Rs 2,360 crore for last year. Again, while in absolute numbers, this seems to be an increase, but when adjusted for inflation for even 5%, it is a decline of 1.87%. The scheme (Poshan 2.0 for providing nutrition) has been allocated Rs 21,200 crore for FY 2024-25, an increase from Rs 20,554.31 crore (budget estimates) from previous financial year. However, when adjusted with inflation of 5%, this allocation is actually a decline of 1.77%.

One worrying feature is that the decline in budgeted expenditure for health with respect to the total budgeted expenditure of the central government is worrying; the health sector outlay has fallen over the years, from 2.66% in 2022–23 and 2.06% in 2023–24 to around 1.98% this year. Additionally, considering the inflation rate of 5.69% in December 2023, health spending in real terms has decreased. In fact, the budgeted expenditure for the two ministries is a meagre 0.27% of the GDP estimate for 2024–25. Following the devastating assault on primary health care during the COVID period one can only expect that public health programmes should be reinvigorated on the one hand, and revitalisation of primary health care on the other. Is it the time to be bamboozled and befooled again?

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Vol 56, No. 36, Mar 3 - 9, 2024