Why this anaemic health budget?

Despite two decades of economic growth, India, Asia’s third-largest economy, continues to invest a miserly amount in healthcare. Although the budget is a little over ₹30,645 crore for 2014-15, it continues to hover around 1.3 per cent of its Gross Domestic Product (GDP), i.e. about 4 per cent of total Government expenditure.

Even among SAARC countries, Afghanistan spends 8.7 per cent of its GDP on health, followed by Maldives at 8.5 per cent and Nepal at 5.5 per cent. As per the WHO Global Health Observatory Data Repository and World Bank, the total expenditure share on health as percentage of GDP for Brazil, South Africa and China stand at 4.7 per cent, 4.3 per cent and 3.1 per cent, respectively.

Under the Constitution, the primary responsibility of providing health care lies with State governments and a bulk of health care expenditure is incurred by them. The Central government gives additional funds to the States for concerns that are of wider interest or impact national wellbeing in different way.

Through the mid-nineties, the Central government incurred expenditure primarily on family planning, select disease control programmes, national-level institutes of medical education, training, research and tertiary-level health care.

With the initiation of the National Rural Health Mission (NRHM) in 2005, the country’s flagship health programme that provides basic medical services to millions of poor people, the Centre also began to incur a substantial amount of expenditure on primary and secondary health care at the state-level.

The NRHM was expanded into the National Health Mission (NHM) in 2013 to include the National Urban Health Mission (NUHM), which further increased the health expenditure incurred by the Centre.

Despite political commitment at highest level to make health care reforms a priority, the Central Government continues to eye the outlays for health, education, agriculture, rural development, etc., to keep the fiscal deficit down.

This was evident in the healthcare budget being slashed by almost 20 per cent in December 2014. Thereafter, instead of keeping up with the promise to increase healthcare funding to 3 per cent of the GDP, previous as well current government chose to hover around 1 per cent of the GDP.

In addition to reducing the budget, whatever amount that gets allocated to health is not fully spent. The system itself has historically struggled to spend the allocated budget.

The choice of re-allocation of underutilised health funds to other sectors that are able to spend the amount has been continuously made over building capacity within the system to utilise the available funds.

The Finance Commission’s decision to economically empower the States by increasing the States’ share from the national pool of tax revenue on one hand seems to be an affirmative action to fix the poor choices made in the past.

On the other hand, it seems to come as a convenient defence to the mere 2 per cent hike in the Union Health and Family Welfare budget. Theoretically, the devolution of funds is expected to make more funds available to States for spending. In reality though, States like Bihar, Uttar Pradesh, Odisha and Andhra Pradesh would get a meagre additional amount.

In addition, the States are now required to allocate an increased share of funding for the National Health Mission to offset the 20 per cent budget cut levied on it.

The family welfare budget in the country has been reduced by 87 per cent in the recent years, from ₹12,278.65 crore in 2013-14 to ₹1605.37 crore in 2014-15. This may have been because most of the family welfare budget was routed through the Reproductive and Child Health programme under the National Health Mission, which subsumed the National Rural Health Mission, erasing the family welfare budget lines.

Of the ₹396.97 crore spent on family planning under the National Health Mission in 2013-14, ₹338.91 crore (85 per cent) was spent on female sterilisation, while the expenditure on spacing methods was a mere ₹5.76 crore (1.45 per cent).

The fact that India has a huge population of young couples who would need to space their children has been conveniently ignored.

By 2020, India aims to reach the goal of averting 42,000 maternal deaths, 12 lakh infant deaths and 2.39 crore births annually. Preoccupation with female sterilisation, reduction in the healthcare budget and poor allocation to family planning does not elicit much confidence in our preparedness to achieve commitments made under Family Planning 2020 (FP2020). FP2020 is an outcome of the 2012 London Summit on Family Planning where the Government of India made a commitment to provide contraceptive services to an additional 48 million users.

A sense of urgency is required to meet the daily unmet need of family planning among the masses. Saving lives in a country of 130 crore cannot be achieved on a shoestring budget with a-one-size-fits-all approach.

It requires increased healthcare allocation taking it up to 3 per cent of GDP, and provision of an expanded choice for spacing methods of contraception to ensure fulfilment of the unmet needs for family planning.

The writer is Executive Director, Population Foundation of India