Health infrastructure in Budget 22, a missed opportunity
The Omicron wave has led to a shortage of healthcare workers throughout the world. In India, healthcare infrastructure wasn’t overwhelmed as was seen during the second wave, mainly due to patients recovering from home quarantine.
However, this was no time for complacency as the WHO and experts around the world were warning against more fatal variants in the future. The time, therefore, was ripe to revamp the overall health infrastructure in the country, from the level of the primary health centres (PHC) to the district hospitals (DH) in the next two-three years, starting right from Budget 2022—just as has been done for building resilience against natural disasters. Instead of a piecemeal incremental model of expansion in gross allocation terms usually followed due to the paucity of funds, the pandemic called for clear goals to convert all PHCs and DHs to a certain level, assess the shortfall and make provision for the amount required to meet these gaps.
However, the Budget proposals, though they speak about the resilience of the existing health set-up including the frontline workers to successfully negotiate the pandemic, fall woefully short in providing for augmentation of this infrastructure. The total allocation at Rs 86,606 crore is a mere 2.19% of the total BE 2022–23 and 0.33% of the GDP compared to last year’s 0.37% (2021–2022) and 0.32% of the year before the last (2020–2021). Comparison in GDP terms is more realistic than using absolute values that might appear to be higher than the previous year. This is indeed a disappointment and a missed opportunity that India would rue in the event of another health hazard or pandemic.
The two vital aspects that are to be taken into consideration in health are: the upgradation of physical infrastructure and increasing the workforce.
Firstly, as per the findings of the High-Level Group on Health Sector, India has only 1 bed per 1,000 people, way below the global average of 2.9. As per the World Bank, Sri Lanka and China with 4.2 and 4.3 beds per 1,000 people perform significantly better than India. While the National Health Policy envisages increasing this to 2 beds per 1,000, geographic access to healthcare with a 30-minute travel time is a simple but meaningful indicator. Innovative solutions using technology have led to cost-effective e-ambulances in Estonia that are powered by solar panels. This author also custom-fabricated auto-ambulances and supplied them in Sundergarh district of Odisha. This has significantly improved accessibility and affordability, especially in rural settings. The government must encourage such small but impactful innovations.
Even though private players are already there in the tertiary healthcare sector, they must be incentivised to invest in primary and secondary healthcare through Public-Private Partnership (PPP) models. Private hospitals in cities must develop some primary and community healthcare facilities as their satellite centres (as currently done by the All India Institute of Medical Sciences) with diagnostics and equipment for simple medical procedures and surgeries. Under the National Health Mission, the invitation for bids for PPP for the maintenance of PHCs and sub-centres is encouraging. The success story of PPP in Bangladesh through the non-profit BRAC helping the healthcare providers and improving the capacity of PHCs could be implemented in rural India.
Secondly, against the WHO recommended 1 doctor per 1,000 people, India has 1 for every 1,511 people as per the report of the 15th Finance Commission. Similarly, the nurse to population ratio in India is 1:670, while the WHO norm is 1:300. As seen in the World Bank data, India and South Africa have nearly 0.9 physicians per 1,000 people but still fare poorly when compared to countries such as Russia and China, which have 4.4 and 2 physicians respectively.
The attainment of this target can be facilitated by opening government or private medical hospitals and colleges in every district. The process and the various stages of issuing approvals for private medical hospitals and colleges must be completely simplified, as currently, it requires around 30 licences for a multi-speciality hospital to come up.
All it does is not improve healthcare but increase rent in the system for middlemen and bureaucrats. The recent relaxation of land requirements for the construction of colleges by the Medical Council of India is welcome. Shifting away from high upfront pre-project compliance and transaction costs, importance should be given to monitoring the quality of patient care and tariffs charged by these units. Countless healthcare procedures and products attract different tariffs; therefore, a uniform fee structure with tariff bands for different procedures set by an independent committee can make such healthcare affordable and equitable.
Hundreds of doctors and healthcare workers have been fighting against the virus for more than two years now and face possible burnout. It is worthwhile to consider Dr Devi Shetty’s suggestion to train the undergraduate qualified doctors who have not passed the PG-NEET examination and get them into our healthcare ecosystem instead of letting them veer away to other avenues of employment.
The various health insurance and assurance schemes announced by the Central and state governments will not be very fruitful unless the root problem of inadequate health infrastructure is addressed. The government should have thought outside the box and provided a massive outlay to establish the best healthcare infrastructure, at least amongst medium-income countries in the next three-four years, to bridge this gap at one go. As a percentage of GDP, India’s expenditure on public health (0.33% of GDP) is too low compared to Norway (11.3%), Finland (7.7%) and Singapore (4.5%). There is a need to revisit the Budget proposals and grab the opportunity.
BJD Rajya Sabha MP, ex-CAG bureaucrat with a PhD in management and now an advocate