The finance minister couldn't have foreseen the gastro-enteritis and cholera episode in the country's financial capital, nor expected the avian flu to continue to spread when he chose to allocate 65 per cent of the entire health and family welfare department's budget to a single politically high-profile programme, the National Rural Health Mission (NRHM). Whatever the merits of boosting the NRHM, should major centrally funded public health programmes suffer in consequence? This also raises another issue laterally. Is anything substantial to be gained by persuading governments to increase funding for health care, when its distribution within the sector continues to be dictated by political convenience rather than health needs and priorities? |
While budget grants for the department this time around have registered an overall rise of 22 per cent over last year, only about 6 per cent of the total is targeted at major disease-control programmes. Under public health, disease-control programmes, some fully funded by the Centre and others receiving reciprocal grants, comprise the bulk. Vector-borne diseases, tuberculosis and leprosy are not diseases that are on the wane. But none of the control programmes for these diseases has seen anything but a nominal rise in budgetary allocations. Rather worrying is the general consensus in government to underplay the incidence of these diseases as a diminishing legacy of a "poor country" past. For instance, leprosy, if we were to believe the finance minister and the health department, is on the decline. And yet, as health activists from Bilaspur and others pointed out in a recent meeting of the Medico Friends Circle, the absence of numbers is likely to be because the data are hospital-based, excluding all those cases that do not come to the public health system. Field workers fear that leprosy, far from declining, is spreading to areas that were not so far affected. |
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Typically, disease-control budgets are not tagged to the incidence or prevalence rates or even to geographical spread of the disease. Disease-surveillance systems are dysfunctional and epidemiological data systems are in shocking disorder. Budget-making in this area is more a matter of arbitrary increases over the previous year's allocations linked to what has been spent or remains unspent over the last year. |
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Can this state of affairs be a consequence of poor investment in health care after 1990? In a post-budget presentation on social sector spending, Mumbai University's Ajit Karnik pointed out that contrary to persistent notions, there has really been no slackening of plan outlays in health care (or in the social sector, in general). Both as a proportion of GDP and of total expenditure plan outlays have steadily risen since the 1990s, even though not as sharply as may have been required. In other words, the problem here is not so much the declines in budgets, but really the skewed distribution of financial resources within the sector as is evident from an examination of the disease-control programme allocations. Public investment in health care must undoubtedly be hiked. But as Karnik pointed out, if health care spending were to rise to 3 per cent of GDP by 2010, then the additional resources required would be of the tune of Rs 180.470 crore. The finance minister's problem is to devise ways and means of generating the necessary resources. |
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There have been many suggestions on this count: link tobacco tax exclusively to health care; do away with "inefficient" subsidies, or designate resources generated from disinvestment of PSUs to the health sector. Whatever their technical feasibility, all of them require the elusive "political will". |
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There is an urgency here that seems to have escaped the attention of policy makers. The resident doctors' strike in Maharashtra served to highlight the shocking state of the public hospital system: the abysmal quality of care, poor services, dismal working conditions and the sharpening doctor-patient divide. Various national surveys show that access to reliable and affordable health care is shrinking and is directly linked to economic class. |
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Private investment has been largely confined to small and medium-sized hospitals and not in large/corporate hospitals, contrary to general assumption. An IIM Ahmedabad study by Ramesh Bhat finds that this is partly because of the inefficiency of the investment structure, including financing patterns, in these hospitals. But the efforts to design better financing plans for these hospital system""by, for instance, introducing user charges""is likely to "tilt the private-public mix of health care expenditure in favour of pocket expenditure", which even now comprises 80 per cent of all health expenditure. |
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At another level, with little regulation on quality and minimum standards of care in private hospitals""in many states small hospitals are governed only by the Shops and Establishment Act""there is no guarantee that even those above poverty line levels, who can afford to purchase health care, can get reliable services. |
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There is a public health crisis in the making. Some might say that it is already upon us. Neither the unprecedented and ad hoc hikes in health budgets nor new programmes like the National Rural Health Mission can stave off this disaster by themselves. There is no way public sector investment alone can reach the proportions needed to change this scenario. We have to stop regarding the widespread private care institutions as the "other", leaving them to function without adequate norms and regulations. If the objective is the provision of ethical, efficient and affordable health care services, then designing an appropriate public-private mix has to be high on the agenda. |
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