Historically, the commitment of any government to the health sector has been judged by its budgetary allocation to the sector. BRICS countries spend on an average between 3.5 and 8.5 percent of their GDP on healthcare. At much less than even 2 percent of the GDP, therefore, it is no surprise that the Indian government has been criticised for keeping public spending on health at abysmal levels over the years.
The correlations with ground reality are obvious. Marginal and sporadic improvements aside, the harsh reality is that 2.9 million children per annum still die in the neo natal period, i.e. the first 4 weeks of life, and 2.87 lakh women die in the post-partum period in India. These two indicators, viz. Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) are usually the two sensitive indicators of well-being in a country. Even countries with a poor history like Nepal and Sri Lanka have shown improvements in these areas and are better off. That aside, thousands of positions of medical staff at primary health centres are vacant. Further, there’s the old, unsolved problem of inadequate doctors in rural areas, aggravated by the inadequate supplies of medicines, vaccines and other disposables. Deplorable by any standards, for a country in the 21st century.
Glancing through the website of the Ministry of Health Affairs, you see that the problems are recognised and efforts made to address them. In fact, the draft Health Policy 2015 is so well enunciated, it seems unbelievable that problems could actually exist, despite such clear understanding, thinking and planning. In theory, all aspects have been covered, infrastructure, spending, monitoring, et al. Yet, it is in the implementation that the problems arise.
On analysis, we find that the problem is two-fold. First: Yes, public expenditure on health needs to go up to 2.5 percent of GDP, as laid down in the Twelfth Five-year plan and also the draft Health Policy, 2015. Lack of funds does come in the way of complete execution of intentions. Like, in the case of Jan Aushadhi Yojana centres (or government pharmacies) that Budget 2016 had announced. Instead of 3000 such centres promised in 2016-17, only 645 have been set up. Since this trend continues with a statedly pro-poor government at the helm of affairs, without doubt, the problem lies not with the intention. The fact is, increasing budgetary allocations is not possible for the simple reason that there is a genuine paucity of funds with government.
But the more important question to be asked here, and which brings us to the second problem, is the efficient allocation of funds. Would an increased budgetary allocation automatically lead to better outcomes? Going by the experts’ opinion – no. For two reasons: one, the planning that accompanies spending is often not most efficacious. An example of this is, Indian government continuing to spending on ad campaigns in mass media, whereas across the globe, that has moved into the more effective digital and social media. The other reason is of course, the existence of multiple agencies, layers of functionaries and the inevitable inefficiency and corruption that ensue. It is this that needs to be addressed, i.e. how, given our constraints, we could better approach the problems and find tenable solutions.
Adopting a bottom-up approach and coming up with innovative and out-of-the-box solutions is the need of the hour. Speaking to players in the healthcare sector, which included doctors, NGOs and start-ups, we zeroed in on the possible next steps, which could define the way ahead.
Starting this budget and then following up and integrating with other programs, the focus should now shift broadly to the following:
Encouraging entrepreneurship in mobile and digital technology apps
Take steps to enhance the use of technology in this sector, using it intelligently and strategically. Mobile apps could be used to get health messages across, digitize health records, monitor health status of patients and pregnant women. Since people are being motivated to buy Smartphones for financial transactions, they could be given, say, 1GB free data for health information on apps approved by government. Aadhar cards could be used to track and coordinate with patients for home delivery of medicines – especially helpful in addressing supplements’ needs of pregnant women and newborns. Apps could be designed for paediatric care – for vaccination reminders and home delivery – just like an Amazon.com!
Coordination between agencies and between Centre and States – health is a State subject – would be easier with easy flow of information through digital and mobile technology. In other countries, technology is, in fact, being used in unimaginable ways: to monitor waiting time of patients at government clinics, for instance, or for ensuring availability of medicines at health centres, etc. Currently, the primary healthcare centres in India are in a pathetic state; rough estimates reveal that only 20 per cent work efficiently, in terms of functioning of the equipment and staff. Monitoring and tracking exists on paper, but is just another inefficient management overhead. The use of technology to track can actually ensure even their efficient running. All this ensures that last-mile individual is empowered, rather than intermediate functionaries.
Another area for encouraging entrepreneurs is in Ambulance Services, which are currently run by government and are not just woefully inadequate currently, but also not financially viable in remote areas. Engaging local entrepreneurs, while putting regulatory guidelines in place, would take care of an important aspect of healthcare where there is a glaring deficiency in our country.
Entrepreneurship could be encouraged in these areas using budget incentives. India is a country of innovative minds and entrepreneurs; the government must thus, list out areas where it could use entrepreneurship, and then through the budget create an entrepreneur-friendly environment so as to encourage investments in various health-related requirements.
Skilling people to work as healthcare workers
Further, Spending could be judiciously reworked, in favor of investing in skilling mid-tier healthcare workers. This would more ably handle the problems at hand, as well as have preventive value, as demonstrated by the experience of other countries. These healthcare workers are a) Trained Midwives, who hand-hold pregnant women from the beginning up to the ante natal period, and the example of Sweden has proven that this single step can reduce the MMR significantly; b) Counselors across categories – for maternal, child and adolescent care, and for special categories of patients such as those with sexually transmitted diseases and other vulnerable categories; c) Consultants in chronic diseases, which are rapidly on the rise such as heart disease, thyroid, diabetes, orthopaedic diseases, etc. The learning from the experience of countries like Sri Lanka and Thailand that encouraged such workers is that they are very effective in halting the progress of these diseases, which need management through sustained lifestyle changes, rather than medical intervention. This kind of skilling would effectively – also cost-effectively -- reduce disease-burden, while providing employment to thousands of people.
Building Medical University Campuses in remote areas
Finally, addressing the problem of doctors in rural areas would involve innovative solutions. Basic needs of adequate and comfortable housing, schools for education of children, etc. would need to be met and there need to be budgetary allocations for that. Out-of-the-box solutions are required. Maybe the Construction industry, reeling currently under the effects of demonetisation can be given amnesty against building housing for this category. Also, the budget could give incentives for setting up new Medical University campuses in rural areas where there is no medical set-up, where doctors are trained, and also provide services to the population around. Tamil Nadu has set a good example in this area.
It is in thinking along these lines that Jaitley and his team must put their efforts. Without these, increasing public health expenditure would amount to mere lip-service!
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Updated Date: Jan 31, 2017 11:49:27 IST