How healthy is the health budget of Amrit Kaal: 2023-24?

ABSTRACT

Political will is the key to public health policy-making and a major driving force for the attainment of Universal Health Coverage (UHC) in any nation. To achieve UHC, the Indian government laid down National Health Policy in 1983 and updated it in 2002 and recently in 2017. This recent policy emphasized increasing healthcare spending and economic growth. In the current budget, there is an increment in the share of GDP of 0.34% from the previous year’s allocation, but still staggering for the envisaged 2.5% to achieve UHC. Enthusiastic announcements of opening 157 new nursing colleges, a separate programme for eliminating sickle cell anemia by 2047, and Centers of excellence establishment for pharma companies for promoting research and development and focusing on Particularly Vulnerable Tribal Groups (PVTGs) are the few overarching and new highlights in the current budget. But, in a country so huge and varied in terms of its needs in every sector, the announcements in the financial budget speech taking India forward in becoming a “shining star” is a matter of debate. This is an attempt to review the budget for this financial year in the healthcare sector and what it means: is the country willing to build a self-driven healthcare sector in the Amrit Kaal with strong public finances and a robust financial sector through “efforts by all”?

Introduction

Amrit Kaal envisions India as a technology-driven and knowledge-based economy with strong public finances and a robust financial sector through “efforts by all.” With this motive, India’s finance minister announced the first budget of the Amrit Kaal on February 1, 2023. The term “Amrit Kaal” comes from Vedic astrology and refers to a crucial period when the gates to greater pleasure for humans, angels, and other creatures open. Amrit Kaal is regarded as the most fortunate time to begin any new work.[1]

Political will is the key to public health policy-making and a major driving force for the attainment of Universal Health Coverage (UHC) in any nation. To achieve UHC, the Indian government laid down National Health Policy in 1983 and updated it in 2002 and recently in 2017. This recent policy emphasized increasing healthcare spending and economic growth.[2] Ayushman Bharat Pradhan Mantri Jan Arogya Yojana the largest health insurance scheme launched in 2018 to cover marginalized populations is also a remarkable step toward achieving UHC.[2]

Though spending on healthcare from the share of Gross domestic product (GDP) has increased year to year from 2014 to 2022 the increase is not uniform.[3] In the current budget also there is an increment in the share of GDP of 0.34% from the previous year’s allocation, but still staggering for the envisaged 2.5% to achieve UHC. Moreover, in comparison to other nations’ expenditure (7.6% on average for countries under Organization for Economic Co-operation and Development (OECD) and 3.6% on average for BRICS countries), this country’s expenditure on public health system is approximately 1.3%.[4] This year’s enhanced budget allocation is also a welcome sign in this regard. But, in a country so huge and varied in terms of its needs in every sector, are the announcements in the financial budget speech taking India forward in becoming a “shining star”?

Ample evidence is there to support that investment in Primary Health Care (PHC) is one of the key elements in the performance of the healthcare system of any nation. This enables primary care service more robust and has better outcomes at lower cost through greater access to the service of primary care physicians.[5,6,7] This is of paramount importance on the part of a primary care physician to have an insight into the budgetary allocation to the health sector in general and to PHC in particular. We attempt to dissect the budget of this financial year in the healthcare sector and to find out what is meant for the health sector. Is the country willing to build a self-driven, healthy, and sustainable healthcare sector to achieve UHC?

Budget allocation on health for the financial year 2023–2024[8]

• The enthusiastic announcement of opening 157 new nursing colleges with existing medical colleges established since 2014 is thought to be a boost to the healthcare sector.

• Separate program for eliminating sickle cell anemia by 2047 through awareness, screening, and counseling.

• Strengthening the research sector by opening Indian Council of Medical Research (ICMR) laboratories through public-private joint ventures.

• Establishment of centers of excellence for pharmaceutical companies for promoting research and development. To support the development of medical devices and the need for skilled manpower, dedicated multidisciplinary courses will also be launched.

• With the realization of the importance of Artificial Intelligence (AI) in growth, three centers of excellence will be created in top educational institutions to promote the same in the health sector as well.

• A 16% increase in National Calamity Contingent Duty (NCCD) has also been proposed to be levied on specified cigarettes, which might play an indirect role in curbing smoking.

• One hundred labs are to be set up for developing applications in the health sector recognizing the importance of technology.

• A whooping ₹15,000 crores have been allocated for the next three years to uplift the health and overall development of particularly vulnerable tribal groups (PVTGs) by providing them with basic facilities of housing, water, and sanitation.

• Apart from increasing the share of the healthcare budget by 0.34% of the GDP, various other programs including National Tele Mental Health Programme, Pradhan Mantri Jan Arogya Yojna, Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM), POSHAN Abhiyan, SAKSHAM Aanganwadi conversion, Pradhan Mantri Awaas Yojna, Jal Jeevan Mission, and Pradhan Mantri Ayushman Bharat Health Insurance Scheme have been allocated higher share compared to the previous year.

• Although this year Ministry of Health and Family Welfare got ₹ 89,155 crores in total compared to ₹ 86,200 crores in comparison to last year which is a 3.4% increase while the revised expenditure of last year was ₹79,145 crores which was lesser than the actual expenditure of ₹84,470 crores in FY 21–22.[9]

Is the health budget for 2023–2024 healthy?

Although there is a 0.34% rise in the health budget share of GDP, has the rise taken into account the rate of inflation? The budget allocation has declined when inflation is taken into account. This shows that the Government is still lagging behind the required spending of 2.5% of its GDP to achieve UHC as envisioned in the National health policy in 2017.[2] Figure 1 shows although there is a gradual improvement with several dips in the trend of the past ten years, there are still a lot of scopes to reach the 2.5% target to allocate to health and give it the due weightage.[3]

Figure 1.

Graph showing allocation of budget to health in past 10 years as percentage share of GDP

While the National Health Mission (NHM) stays to be one of the most important components of our health system, the allocation has declined by ₹375 crores in comparison to last year.[9] Decreasing this allocation is bound to impact the structural framework of one of the most important services being provided to pregnant women and children. Allocation to Pradhan Mantri Matru Vandana Yojana has also declined by ₹41 crores.[10] Mission Shakti, which aims to work for women’s empowerment and security, has also received a decline of ₹40 crores from ₹3,184 crores last year to ₹3,144 crores. On one hand, we are curbing the expenditure on women’s and children’s health, but Mission Vatsalya which supports children’s development and child protection priorities aligned with the Sustainable Development Goals (SDGs) with the motto to “leave no child behind” through non-institutional care under private aided sponsorship has received ₹1,472 crores. Although how much has been already spent and what outputs have come out of it is a separate discussion altogether. Allocation for Saksham Aanganwadi and POSHAN 2.0 has increased but a check on how many Aanganwadis have been upgraded to Saksham Aanganwadi is important to analyze the appropriate utilization and further estimation as well.[10] The current status says that 35,758 AWCs have been approved for upgradation in 24 states. So far so good, but the journey from approval to the status of being operational is in itself long.[11]

Even the increased allocation in Pradhan Mantri Jan Arogya Yojna (PM-JAY) and Ayushmaan Bharat Health Insurance Scheme from ₹4117 crores to ₹4200 crores and ₹6457 crores to ₹7200 crores, respectively, are not benefitting much to the public sector since most of this money is being transferred to the private sectors.[12] Instead of strengthening our government hospitals to provide better facilities and infrastructure, we are determined to pay a handsome amount to the private sector for our patient care. SAMBAL scheme gets the same ₹ 562 crores as the previous year which is a decline.[13]

While we continue to focus on the National Tele Mental Health Program and allocate a 10.52% rise from ₹121 crores to ₹133.73 crores this year, the National Mental Health Program already running continues to receive a bare minimum only. Starting a new program with such huge investments could have been secondary to strengthening the already running programs that can bring about a substantial change in the field.[13]

Ayushman Bharat Digital Health Mission: Allocation increases from ₹200 crores to ₹341 crores accounting for a 70.51% rise. Is India at such a stage where the basic needs are being neglected and digitalization is being paid so much focus especially when the mission is already spending less than allocated in previous years?[13] Allocation changes (as a percentage) in centrally sponsored schemes in 2023–2024 in comparison with 2022–2023 are given in Figure 2.[14] A measurable achievement is that the Total Ayushman Bharat Health Account (ABHA) numbers created so far is 27,46,56,356 and ABHA mobile app downloads are 10,00,221, but we need to assess if India is at such a stage where the basic needs are being neglected and digitalization is being paid so much focus especially when the mission is already spending less than allocated in previous years?[15] Though the ICMR budget has increased in comparison to the last year from ₹2,198 crores to ₹2,359 crores, the actual expenditure last year was only ₹1,841 crores.[16] Alongside research, even the education and clinical care under Pradhan Mantri Swasthya Suraksha Yojna (PMSSY) has received a cut from ₹10,000 crores in 2022–2023 to ₹3,365 crores this year. While support has been given for research in the pharma industry, creating multidisciplinary courses for medical devices, focus on the vaccine industry is somewhere lost in the priority list.[16]

Figure 2.

Budget estimate shifts in 2023–24 from 2022–23 in percentage

PM-PVTG Development Mission envisaged to improve socio-economic conditions of the PVTGs, Pradhan Mantri PVTG Development Mission will be launched. This will saturate PVTG families and habitations with basic facilities such as safe housing; clean drinking water and sanitation; improved access to education; health and nutrition; road and telecom connectivity; and sustainable livelihood opportunities. An amount of ₹15,000 crores will be made available to implement the mission in the next three years under the Development Action Plan for the Scheduled Tribes. Hope this enthusiastic initiative may push tribal health and well-being to a new high.[17]

The breakthrough has been achieved in PM Awaas Yojna where 2.12 crore houses have already been handed over and proposes to provide homes to 2.94 crores with an increased allocation of 66% year to year (₹48,000 crores to ₹79,950 crores). Jal Jeevan Mission also got a hike in allocation (₹60,000 crores to ₹70,000 crores) to provide water to 20 crore households, which is 11 crores at present and a substantial increase from 3 crores in 2019. These initiatives on the social determinant of health will have a definite edge in curbing certain communicable diseases.[18] Another important lesson that should have been incorporated into the budget post-pandemic is an approach toward preventive care through immunization where no budget allocation has been talked about COVID-19 vaccinations. Looks like the whole vaccination drive was only to stand out during the immediate post-pandemic period and concern was only on the figures while health has been ignored smartly.[17] While all major programs have received a decline, the launch of the Sickle Cell Anemia Elimination Mission targeted to eliminate sickle cell anemia from India by 2047 has grabbed all the attention. The mission targeted to eliminate sickle cell anemia through awareness and screening of the 0-40 year-aged population.[18] Though this seems a herculean task elimination can be partially achieved by screening populations at risk (high-risk communities) for sickle cell trait. Individuals with sickle cell trait will be identified through mass screening and should be motivated not to marry each other since there is a 25% chance of having a baby with sickle cell disease. If they get pregnant, then we need to screen the fetus for sickle cell disease and terminate the pregnancy with the parent’s consent. Extensive public awareness is mandated because it is caused by a consanguineous marriage which can be avoided.

Discussion

Looking at all the components of the budget in the healthcare sector, one thing is for sure the Government is still not ready to give the due focus which is required. The health budget is again the last according to the share received of the budget. Apart from this, another worrisome issue is that whatever amount is being allocated to different programs and schemes, it is still not being utilized effectively and totally.[9] A higher share compared to the previous year has been allocated to the program that focuses on PHC and UHC, viz. National Tele Mental Health Programme, POSHAN Abhiyan, Pradhan Mantri-Ayushman Bharat Health Insurance Scheme, is encouraging though, future trends of not expanding to their fullest are still discouraging. India stands at a crossroads where it needs to move ahead taking together the poor as well as digitalization and technology growth. While Amrit Kaal focuses on the technology and knowledge-based economy, the poor must not be neglected.

Key take-home message

To conclude, the health budget 2023–2024 is enthusiastic about providing PHC and heading toward universal health coverage. The announcement of the opening of 157 new nursing colleges will boost the healthcare sector. A separate program for eliminating sickle cell anemia by 2047 is a welcome sign in preventing sick cell anemia through awareness and screening of the 0–40 year-aged population. Initiatives to strengthen medical research and innovation by opening ICMR laboratories and centers of excellence for pharma companies are the need of the hour. Giving due consideration to the fact that the health of a nation is reflected by the health status of vulnerable groups, the focus has been given to uplifting the health and overall development of PVTGs by providing them with basic facilities of housing, water, and sanitation. Furthermore, increasing the share of the healthcare budget by 0.34% of the GDP, various other programs which focus on primary healthcare and UHC, viz. National Tele Mental Health Programme, POSHAN Abhiyan, and Pradhan Mantri-Ayushman Bharat Health Insurance Scheme, is commanding.

The bottleneck identified is the expenditure incurred is lesser on year-to-year basis.[9] Though there is an increment in the share of GDP of 0.34% from the previous year’s allocation but still staggering for the envisaged 2.5% to achieve Universal Health Coverage. Increase allocation to Pradhan Mantri Jan Arogya Yojna (PM-JAY) and Ayushman Bharat Health Insurance Scheme as compared to the previous year are not benefitting much to the public sector since most of this money is being transferred to the private sectors.[12] Instead of strengthening our government hospitals to provide better facilities and infrastructure, we are determined to pay a handsome amount to the private sector for our patient care. While the focus is on research and development, AI is a must to stay in tune with the growing economy globally but not at the cost of cutting down our focus on women and child health which is a direct indicator of the health status of a country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.