About 20 years ago, Thailand rolled out universal health coverage for its population at a per capita GDP similar to today’s India. What made this possible was a three decade-long tradition of investing gradually but steadily in public health infrastructure and manpower. This meant that alongside the availability of funds, there also existed robust institutional capacity to assimilate those funds. For India, the lesson of COVID-19 entails setting forth on a steady and incremental path to universal health coverage; not attempting a sudden and giant leap. This is important because enough evidence exists on weak fund-absorbing capacities particularly in the backward States — at times, such unused funds have been to the tune of over half of the State’s public health expenditure.
The Union Ministry of Health and Family Welfare budget for 2021-22, viz . ₹73,932 crore, saw a 10.2% increase over the Budget estimate (BE) of 2020-21 — a modest increase even nominally. Also, a corpus of ₹64,180 crore over six years has been set aside under the PM Atma Nirbhar Swasth Bharat Yojana, (PMANSBY) for strengthening health institutions, and ₹13,192 crore has been allocated as a Finance Commission grant. While the allocations still leave a lot to be desired, these could make the first steps of a journey that steadily builds towards sustainable universal health coverage through incremental strengthening of grass-root-level institutions and processes. Two important and prominent arms of universal health coverage in India merit discussion here.
The BE for the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which covers over 50 crore poor Indians for hospital expenses up to ₹5 lakh per annum, has stagnated at ₹6,400 crore for the current and the preceding couple of years. And so have the actuals and revised estimates at around 50% of the BEs, which should be cause for concern. Large expenditure projections and time constraints involved in input-based strengthening of public health care have inspired the shift to the insurance route for achieving universal health coverage.
However, insurance does not provide a magic formula for expanding health care with measly levels of public spending. Available estimates have pegged the costs to be between ₹62,000 crore and ₹1,08,000 crore for 2021, if PM-JAY is to meet its stated commitments. Given these circumstances, making do with such paltry spending year after year would mean that the scheme benefits are being spread out too narrowly or too thin, implying the inability to afford enough protection against catastrophic health expenses to the poor. Beyond low allocations, poor budget reliability merits attention. Another related issue is the persistent and large discrepancies between official coverage figures and survey figures (for e.g. the National Sample Surveys, or NSS, and National Family Health Survey) across Indian States, indicating that official public health insurance coverage fails to translate into actual coverage on the ground. This is particularly intriguing for forward States such as Maharashtra, Gujarat, and Karnataka, where state-level public health insurance schemes have been operational for around a decade. Robust research into the implementational issues responsible for such discrepancies and addressing them is warranted. Without the same, the PM-JAY’s quest for universal health coverage is likely to be precarious.
Finally, even high actual coverage should not be equated with effective financial protection. For example, Andhra Pradesh has among the highest public health insurance coverage scores (71.36%, NSS 75), but still has an out-of-pocket spending share much above the national average (72.2% of total health expenditure). In contrast, Himachal Pradesh (H.P.)with a much lower public health insurance coverage (3.87%, NSS 75) has a lower out-of-pocket (46.4%). Among other factors, this could be attributable to the much higher per capita public health spending in H.P., more than twice that of Andhra Pradesh, which highlights the importance of government investment.
Comprehensive primary care
Health and Wellness Centres — 1,50,202 of them — offering a comprehensive range of primary health-care services are to be operationalised until December 2022. Of these, 1,19,628 would be upgraded sub health centres and the remaining would be primary health centres and urban primary health centres. Initially, most States prioritised primary health centres/urban primary health centres for upgradation over sub health centres, since the former required fewer additional investments. Till February 2, 58,155 health and wellness centres were operational, of which 34,733 were sub health centres and 23,422 were primary health centres/urban primary health centres. This means that of the remaining 92,047 health and wellness centres to be operationalised by December 2022, 84,895 will be sub health centres. This offers huge cost projections — as per early (conservative) estimates, turning a sub health centre into a health and wellness centre would require around ₹17.5 lakh, and around ₹8 lakh annually to run it thereafter.
The current allocation of ₹1,900 crore, an increase of ₹300 crore from previous year, is a paltry sum in comparison. Since 2018-19, when the health and wellness centre initiative began, allocations have not kept pace with the rising targets each year. Additional funding under the PMANSBY and Finance Commission grants is reassuring, but a greater focus on rural health and wellness centres would be warranted.
Issues with funds
Two untoward implications could result from under-investing and spreading funds too thinly. Continuing the expansion of health and wellness centres without enough funding would mean that the full range of promised services will not be available, thus rendering the mission to be more of a re-branding exercise. Second, under-funding would squander an opportunity for the health and wellness centre initiative to at least partially redress the traditional rural-urban dichotomy by bolstering curative primary care in rural areas. This opportunity arises on account of the expanded array of services that health and wellness centres are supposed to provide, and the fact that an overwhelming majority of them will be in rural areas. Since curative care implies larger costs, they could be largely confined to delivering merely preventive, wellness, and referral services without adequate funding.
COVID-19 has prodded us to make a somewhat stout beginning in terms of investing in health. The key, and the most difficult part, would be to keep the momentum going unswervingly.
Dr. Soham D. Bhaduri is a physician, public health policy researcher and commentator