Why India must raise health budget to tackle impending climate disasters

With the Covid-19 crisis having laid bare the poor state of India’s healthcare system, experts warn that India is under-prepared for another brewing global crisis--climate change.

Extreme weather events are predicted to bring heat- and humidity-related mortality and morbidity, infectious diseases following floods and storms, and malnutrition resulting from frequent crop failures, according to experts. “The healthcare system will have to prepare for the myriad health endpoints known to be associated with climate change,” said V. Ramana Dhara, professor at the Indian Institute of Public Health, Hyderabad. Rising sea levels will have health effects from population displacement, including injury, illness and malnutrition, among others, he said.

Mitigation measures will have to include increasing expenditure on healthcare, ensuring systems that include best practices, and improving the quality of data-gathering to make decisions backed by evidence, said experts.

Begin with the basics

India is the fifth most vulnerable country to climate change according to the 15th edition of the Global Climate Risk Index 2020 prepared by the Bonn-based think-tank, Germanwatch.

To begin to address this challenge, India must increase its health spending to 2.5% of its gross domestic product (GDP), experts told IndiaSpend. Covid-19 has already exposed the vulnerabilities in India’s public healthcare system funding, which has been stagnant at 1% of the country’s GDP for nearly 15 years. Patients have been left to the mercy of the private healthcare system, where the quality of care is known to be uneven and prices punishingly high, as IndiaSpend has been reporting through the pandemic.

India spent Rs 1,657 per capita on health in 2017-18, according to the National Health Profile 2019, but, health experts have estimated, it should be spending closer to Rs 4,000 per head to cope with the additional pressures of climate change. India is also short on healthcare practitioners: the country has 7.776 physicians per 10,000 population as opposed to an ideal of 10, according to the World Health Organization.

Fix primary healthcare

The scientific consensus has been that global warming must be limited to 1.5°C by the turn of this century to delay the worst impacts of climate change. In India, in the best-case scenario, the average temperature is likely to rise by 2.4 degree Celsius (°C) by the turn of the century, according to a report by a group of Indian scientists prepared for the Union Ministry of Earth Sciences (MoES) and released on June 14, 2020.

This will make extreme events such as heat waves, floods and cyclones more frequent, more intense. India's coastal areas are likely to be inundated within the next few decades, according to emerging scientific evidence. The healthcare system will have to step up to deal with additional challenges and the resultant pressure will be felt most by those in fields such as family medicine, internal medicine, paediatrics, geriatrics and psychiatry, according to studies.

Hindu devotees crossing the flooded area due to overflowing of river Ganga, in Prayagraj on Sunday.

Extreme events such as the aftermath of a flood, for instance, will create conditions for transmission of infectious diseases and allow diarrhoeal and other bacterial and viral illnesses to flourish, according to studies. India does not adequately study or track many of these diseases, especially the zoonotic ones that originate in animals and hence it is hard to quantify them, as IndiaSpend explored in an earlier story.

These diseases will strain India’s primary healthcare network that is already short of resources, medicines and care providers. Primary health centres and outpatient departments of hospitals are where those with emerging vector-borne diseases will first turn to. Climate change is also set to push up demand for emergency medicine services and outpatient services.

Spending on primary healthcare has lagged in both urban and rural areas in India.

Of the 156,231 sub-centres in India that are responsible for delivering the most basic healthcare, 78,569 were without male health workers, 6,371 without auxiliary nurse midwives and 4,243 without either, according to Rural Health Statistics, 2017.

The primary healthcare centres that form tier-2 of the basic healthcare structure require 25,650 doctors across India to tend to a minimum of 40 patients per doctor per day for outpatient care, as per Indian Public Health Standards (IPHS). If these standards are met, 1 million patients could benefit everyday. But with a shortage of 3,027 doctors, 1,974 PHCs are without doctors. This means that 12%, or 121,080 patients, go without access to primary healthcare every day, as IndiaSpend elaborated earlier.

India’s rural healthcare system, that needs to be strong to protect millions from the impacts of climate change, leaves out the poorest it is meant to serve, as IndiaSpend has reported earlier. Climate change is set to affect the poorest communities the most though they played a limited or almost no role in creating the climate crisis driven by the burning of fossil fuels.

8% of state budgets for health

India has voiced the need to invest in primary healthcare but the budgetary allowances have not kept pace with the announcements, said experts.

“The health policy does talk about strengthening primary healthcare via Health and Wellness Centres (HWCs) that would provide comprehensive primary healthcare but unfortunately budgetary allocations have not been made in line with such a policy that was announced in 2017,” said Ravi Duggal, independent public health researcher and activist. “If India follows the 2017 health policy, the budget should immediately get ramped up to 2.5% of GDP.”

Police personnel stop commuters as they flouting lockdown norms, in Varanasi.

In India, healthcare costs are shared between the Centre and the states, but state governments are responsible for the bulk of the expenses. Ramping up spending would require the states to spend at least 8% of their budgets on healthcare, which would cover nearly 60% of public health spending, while the Centre would be obligated to provide the balance 40%, said Duggal.

Only Delhi and Puducherry are projected to reach this number [8%], based on the Reserve Bank of India’s study of the state government’s budgets for 2019-20.

The mitigation measures for improving public health also lie outside the healthcare system, said experts.

“Provision of safe and clean drinking water, prevention of heat-related illness by reduction of working hours, adequate provision of safe drinking water, rest periods and housing for working populations” would be key in reducing stress on the healthcare system, according to Dhara. Reduction in greenhouse gas emissions and pollution too would be important.

Delivering India’s latest budget speech in February, finance minister Nirmala Sitharaman alluded to the preparations for climate change but remained vague on the specifics. “Every department should have health focus,” said Vikas Desai, technical director at the Urban Health and Climate Resilience Center of Excellence (UHCRCE) in Surat. “It is easy to say that you will design a budget with climate focus but departments should have clarity on what they should focus on.”

Need for surveillance, data collection

A warmer climate might affect other diseases endemic to South Asia including mosquito-borne diseases such as chikungunya and dengue, parasitic diseases such as leishmaniasis, lymphatic filariasis and onchocerciasis, and tick-borne diseases. As temperatures change, vector populations of mosquitoes, for instance, will be affected. This in turn may lead to changes in transmission intensity or shifts in the geographical ranges where the diseases are found.

India, along with other countries in the world, will have to expand surveillance activities to detect the shifting patterns of diseases, according to emerging research.

"There are many efforts now to improve the data collection and its quality throughout the country," said Desai. “What is required is the standardisation of data and the creation of some department or involvement of an organisation that views the health data along with climate data.”

Solutions will require stakeholders like governments, NGOs and research institutes, among others, to bridge knowledge gaps. Efforts will have to be made to invest in infectious disease diagnostics, surveillance and improving access to essential medicines, various research papers have shown.

Evidence on the public health impacts of climate change is not new. They were highlighted as far back as 2007 in the report of the Intergovernmental Panel on Climate Change, the UN body created to assess science related to climate change.

There are countries and regions that have taken initiatives to act.

Learning from best practices 

All European member countries of the WHO have declared their commitment to share their experiences on strengthening health resilience in pilot initiatives and development. Over two dozen of these European countries have assessments of their national health vulnerability as well as adaptation. Africa too has established a regional process to identify the country-specific health risks associated with climate change and ways to enable respective health systems to prepare, respond and share best practices.

While India has not increased health spending at the central level, some states have increased their investment in primary healthcare. Mizoram, Sikkim, Puducherry, Goa, Andaman and Nicobar Islands, Himachal Pradesh and Arunachal Pradesh, for example, spend amounts close to to the ideal of Rs 4,000 per capita, said Duggal.

Separate budget allocations might not be needed to deal with the public health impacts of climate change. “If we have a robust primary healthcare system, climate change issues impacting health would be well taken care of,” Duggal added.

(Shetty is a reporting fellow with IndiaSpend.)