A man cleans an ambulance before exiting the isolation ward for COVID-19 patients at Kochi Medical College, February 2020. Photo: PTI.
The Government of India has allocated highly inadequate sums for health in its COVID-19 stimulus package. On April 21, the government announced that Rs 15,000 crore has been allocated to the health sector. However, only Rs 7,774 crore of this (51.8%) is available now; the rest is for the medium-term, over the next one to four years. And of this Rs 7,774 crore, Rs 3,000 crore has been allocated to states and union territories to strengthen health systems. The remaining Rs 4,774 crore is for diagnostics, enhancing laboratories and purchasing equipment.
In May 2020, the PM CARES fund allocated Rs 2,100 crores for healthcare. Of this, Rs 2,000 crore has been earmarked for buying ventilators and Rs 100 crore for developing vaccines.
While the finance minister announced a few new initiatives on May 17 – such as setting up infectious disease blocks in districts – there was no new allocation.
In sum, a total of Rs 9,874 crore – which is Rs 7,774 crore from the government and Rs 2,100 crore from PM CARES – have been allocated for health thus far. This is about 5% of the total fiscal cost of Rs 2 lakh crore. In absolute as well as relative terms, this amount is woefully inadequate to manage such a crisis.
Allocations before the pandemic
Despite modest increases in the budgetary outlay over the last year, India continues to spend among the least amounts on public healthcare: 1.1% of GDP. The National Health Policy recommends increasing healthcare expenditure – centre and state combined – to 2.5% and that states increase allocations to 8% of their total budget. In fact, the Union health budget has been almost stagnant since 2015. All states except Delhi also allocate much less than the recommended 8%.
To make matters worse, allocations to some of the top-end medical institutes in the country, such as All India Institute of Medical Sciences, New Delhi, and the National Institute of Mental Health and Allied Neurological Sciences, were slashed in early 2020. Allocations to primary healthcare also remained highly inadequate.
The COVID-19 pandemic has brought the importance of public health systems back to the fore. Government hospitals in both urban and rural areas, and primary health centres (PHCs) and community health centres (CHCs) in rural areas, are leading India’s efforts to manage its epidemic. For example, most labs qualified to test for COVID-19 are public-funded, and almost all COVID-19 patients are being managed in public hospitals. Public health staff also conduct surveillance, home isolation, contact tracing and follow-ups. So it’s clear that the epidemic could not have been managed, even if only to the extent that it has been, if we didn’t have such an extensive network of public healthcare facilities.
However, these same facilities have been weakened by years of underfunding, and currently struggle to provide care for non-COVID-19 conditions. The situation is exacerbated by restricted movement and difficulty in accessing care. For example, an analysis of data from the National Health Mission indicated that 450,000 fewer children were immunised in the lockdown months, and 30% fewer women with obstetric complications presented to healthcare facilities. A survey by the Stop TB partnership showed that tuberculosis notification in India had also dropped by 80% in the first month of the lockdown (March 24 to April 24).
Need for a funds infusion
Managing the epidemic and providing the full complement of healthcare will require extraordinary resources and investment. The situation will be further complicated as the public healthcare system will need to manage seasonal epidemics of other diseases as well, such as dengue, malaria and encephalitis.
Government hospitals, especially in North India, continue to be overstretched, understaffed and of poor quality. Reports of children’s deaths clustered in areas such as Kota and Gorakhpur even before COVID-19 came to India reflect the persistent under-investment in public health systems in these states (Rajasthan and Uttar Pradesh).
Data collected in the Rural Health Statistics 2018-2019 shows that about 28,000 sub-centres don’t have water supply and 40,000 don’t have electricity. Similarly, about 1,500 PHCs also don’t have water supply. According to an analysis of data collected by the District Level Household and Facility Survey in 2012-2014, 30% of PHCs and CHCs didn’t have any oxygen cylinders. Finally, PHCs in some states have enough stock of essential drugs and supplies, but those in most states don’t.
In addition, PHCs and CHCs are also together short of about 3,600 doctors, 12,000 nurses, 15,000 lab technicians and 9,000 pharmacists, and even with them, they wouldn’t have as many skilled personnel as the Indian Public Health Standards require. The data also excludes several states that did not report their respective figures. So these numbers are significant underestimates.
The Government of India’s stimulus and response package has overlooked all of these issues, and will thus fail to strengthen the health sector. The package should instead have provided funds to ensure the availability of all basic amenities and drugs in all public facilities, and to recruit all deficient staff at full salaries. It is only an indication of the precariousness of our situation that even Rs 9,874 crore is grossly insufficient, but it is also telling that a government that should have known this is unwilling to commit more to manage the epidemic as well as the challenges that still await us after.