Health was unlikely to be the highlight of Union Budget 2022-23, given the flurry of novel and semi-novel health sector announcements that were made last year. However, what was indeed expected was that it would be an essential “follow-on” Budget that would adequately buttress the already rolled-out initiatives and their targets, whose need have been keenly felt during the Covid-19 pandemic. Unfortunately, some basal contradictions have come to characterise this area.

The expenditure budget for the Department of Health and Family Welfare this year saw a rise in share of capital expenditure from 4.6 per cent in 2021-22 to 6.8 per cent in 2022-23 (RE to BE, all in nominal terms). This is comprised mainly of the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY), a central sector scheme meant to strengthen tertiary health care services through construction of new All India Institute of Medical Sciences (AIIMS) and upgradation of government medical colleges, which saw a 35 per cent increase.

Apart from expanding tertiary care services, an important aim of the PMSSY is to enhance training facilities for medical personnel. Similarly, the budget for Human Resources of Health and Medical Education saw a 34 per cent increase, meant for establishing new medical colleges and increasing the number of seats in the existing ones. The increases from BE to BE are bigger.

The Fifteenth Finance Commission health sector grants announced last year, apart from focussing on critical care infrastructure, made significant appropriations for supporting postgraduate medical courses in district hospitals and training allied healthcare professionals at district and sub-divisional hospitals.

Clearly, health of human resources seems to be getting its rightful emphasis in the Covid-19 aftermath, which has been a critical element limiting Covid- and non-Covid care during the pandemic. Accompanied by concomitant initiatives to strengthen hospital care infrastructure from the district-level upwards, this is a propitious development. A greater attention to allied healthcare workers is warranted though, however much we expect the States to step in.

Minor increase

But alongside the emphasis on critical and tertiary care, one would expect a concomitant attention to primary healthcare whose importance has been so keenly brought out by Covid-19. Appropriations in this regard were not only disappointing but also dismaying. The allocation for the National Health Mission (NHM, India’s flagship programme in primary health care) again saw only a minor increase.

However, more importantly, the core and most crucial components of the NHM collectively saw a 7.1 per cent decline from 2021-22 (BE to BE), while the RE for 2021-22 was 9 per cent lesser than the BE of the same year. This would include the allocation for Health and Wellness Centres (HWCs), of which India aims to build 1.5 lakh until December 2022.

As of December 2021, India was nowhere close to accomplishing this target. Again, significant appropriations were announced for HWCs under the Finance Commission grants and PM ABHIM, but it seems these are having a substitution effect on MOHFW allocations for HWCs, unlike in the case of health human resources where they are complementary.

One reason for the slowing of the HWC initiative in the last couple of years could be the Covid-19 pandemic itself. However, the Centre should have expressed a stronger resolve by making larger budgetary appropriations for primary care this year, just like that for human resources and tertiary care, and the reason for its absence is intriguing.

Similarly, the Pradhan Mantri Jan Arogya Yojana (PMJAY), India’s flagship publicly financed health insurance scheme, received an allocation of nearly ₹6,400 crore for the fourth year in a row now, even as REs and actuals continue to hover around 50 percent of the BE or less.

Cost projections for the PMJAY, offered by a study commissioned by the Fifteenth Finance Commission itself, are several times larger if the scheme is to perform satisfactorily. Again, the pandemic-induced slowdown in hospital admissions could be one factor, however, it seems incapable of explaining this huge disparity. We need to note that HWCs and the PMJAY are our proposed prime handles for achieving universal healthcare.

In the absence of more consequential announcements, the National Digital Health Mission (NDHM, with an allocation of ₹200 crore) and a National Tele Mental Health Programme for quality mental health counselling were the key highlights for the health sector. These are welcome, and the NDHM in particular has the potential to induce far-reaching systemic reforms in India’s health ecosystem. However, there is a need of viewing allocations from a sector-wide perspective, embracing the fundamentals which underpin these higher order initiatives.

The writer is a physician, health policy expert, and chief editor of ‘The Indian Practitioner’