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Union Budget 2021 and the spirit of public health

Several experts in the fields of economics, health, nutrition, etc. have commented on different aspects of the budget, released by the Government of India on February 1, 2021. This article looks at what the budget could have included if it had to incorporate the true spirit of public health in the Indian setting. The questions need to be answered are:

* Will out-of-pocket expenditure on healthcare reduce or stop?

* Will prevention of disease take priority over expensive curative and rehabilitative care?

* Will healthcare become more accessible to Indians, a vast majority of whom reel between an insufficient public health system and an exploitative, unregulated private healthcare?

* Have lessons on public health been learnt from the COVID-19 pandemic?

Public health – need of the hour
In a heart-rending opening statement to the budget, finance minister Nirmala Sitharaman said, “we could not have imagined that people would have to endure the loss of near and dear ones and suffer the hardships brought about due to a health crisis”. However, the unfortunate truth is that a well-planned and responsive public health system would have anticipated a natural or human-made disaster and been somewhat better prepared for it.

Some of the gaps that the budget failed to address are:

Invisibilised health workforce
The pandemic has spotlighted the hazardous working conditions of the health workforce at the lower end of the caste, class and gender spectrum: cleaners, ASHA workers, Group D employees, mortuary workers, sweepers, sanitation workers, auto-tipper drivers and mortuary/ambulance drivers.

Even when equipment is provided, it is not ergonomically designed and doesn’t protect their operators from occupational hazards. Outsourcing or contracting out essential services such as those provided by these frontline workers means they fall outside the ambit of usual regulatory mechanisms, and are therefore more vulnerable to exploitation and occupation-related injuries and illnesses.

The accredited social health activists, or ASHA workers, have been lauded for being the eyes, ears, arms and feet of the health system. Again, ironically, they are the most poorly paid in the health system, depending mostly on the whims of others for their ‘honorarium’.

Whether it is compensating for occupational ill health, providing work-specific PPE kits, enforcing labour laws, regularising jobs, easing access to comprehensive healthcare, or providing adequate rest and holidays – it is high time the government foregrounds these frontline workers.

Private healthcare and PMJAY
The 2021-2022 budget cleverly avoids mention of the private health sector. Does this mean the government is not funding private hospitals henceforth? The answer lies in the Rs 6,400 crore sanctioned under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), in spite of revised estimates being almost half, at Rs 3,100 crore.

This scheme purports to cover the “bottom 40% of poor and vulnerable households”, as identified by the Socio-Economic Caste Census (2011) for rural and urban areas, covering secondary and tertiary care through a network of public and empanelled private healthcare providers.

However, the scheme fails on several fronts – as evident in the 2018-2019 annual report of the National Health Authority.

Although claiming to be universal, it doesn’t cover the entire population nor all morbidities. In April 2019, 554 packages were discontinued, the rates of 57 packages were reduced and 237 new packages were added. For actions taken against several hospitals, see this figure:

Grievances, according to the report, were mostly (93%) about money collected from patients. A fifth of hospitals in the country accounted for 17% of high value claims!

A working paper to assess the impact of the PMJAY showed that hysterectomy comprised 2% of claims submitted by women and 1% of all claims across 24 states and UTs, with 68.7% of all claims in the private sector and the primary type being salpingo-oophorectomy. The consequences of this – early menopause, osteoporosis, cardiovascular disease, etc. – are largely lost on the government’s radar of things to be concerned about.

A preliminary analysis in Jharkhand showed that of the 4,047 deliveries claimed under the PMJAY scheme, 63% also utilised neonatal packages – more in private hospitals (86%), which also tended to claim for intensive (Rs 5,000/day), advanced (Rs 6,000/day) or critical (Rs 7,000/day) neonatal care packages as opposed to the basic (Rs 500/day) ones.

The median length of stay for the advanced and critical neonatal care package was nine and 12.5 days, respectively, in private hospitals versus six and eight days in public hospitals. It would seem reasonable from this analysis to budget to strengthen neonatal services in public hospitals instead of lining corporate hospitals’ pockets.

But contrary to this expectation, the government, in its Economic Survey analysis, misinterprets data where West Bengal, which adopted the PMJAY and then left the scheme, is projected as performing worse than its neighbouring states (Bihar, Sikkim, Assam) which adopted it. Quoting from the study:

“While infant and child mortality declined for all states, the decline has been sharper for states that implemented PM-JAY. While IMR declined by 20% for West Bengal, the decline for the three neighbours was higher at 28%. Similarly, while Bengal saw a fall of 20% in its Under-5 mortality rate, the neighbours witnessed a 27% reduction. The reduction in neonatal mortality rates were similar for the four states: 30% for West Bengal and a marginally higher 31% for the three neighbours”.

However, as we can see, the graph highlights only a change in percentage instead of actual rates, and so fails to give the true picture. West Bengal has actually brought down its IMR from 28 (NFHS-4) to 22 (NFHS-5); the other three states brought IMR down from 42 to 30.

The budgeting by the government for integrated public health labs is a welcome decision that will hopefully reduce out of pocket expenditure and travel time for people, and allow for better data on common diseases. Laboratory personnel have to be adequately trained and these labs should have strict quality control mechanisms.

The budget is also expected to support 17,788 rural and 11,024 urban health and wellness centres. These centres, unlike the primary health centres, are becoming nothing more than telemedicine outposts, totally incapable of managing even basic healthcare needs, and routing patients to more expensive secondary and tertiary private facilities.

Fifteen health emergency operation centres have been budgeted but it is not clear how they will be operationalised – or how 15 centres could meet the emergency health needs of the country. Ideally, this facility should have been made available at the very least at the district hospital level, as an integral part of healthcare.

Need for a public health cadre
The task force – if there was one – that advised the government during the COVID-19 pandemic has made a series of bad decisions that has plunged the country several years into the past.

Decisions to convert major tertiary public healthcare facilities to COVID-19 facilities, shutting down public transport, forcing ‘social distancing’, shutting down schools, and letting essential services like pensions, food security and health services break down – these all have devastated the country and further aggravated the health crisis.

There is a need for a competent task force that has access to resources and evidence, functions with independence and is also held accountable for bad or ill-informed decisions. India needs to develop its own model of healthcare keeping in mind the situation of the vast majority of its people rather than expert-driven, top-down, corporate-friendly models or ‘cut and pasted’ international responses.

Reliable and comprehensive data
The budget hasn’t accounted for pandemic-related health crises such as increase in vaccine preventable diseases, increase in domestic violence, child abuse and sexual abuse, dropout of children and increase in child/bonded labour, resurgence of severe forms of malnutrition and nutritional deficiencies, drug resistance due to erratic treatment, etc.

There is an urgent need for a reliable, dynamic database on health indicators that is not for sale to companies or private agencies. This data should be the basis of informed planning rather than arbitrary ‘recommendations’ by vested interests. Facilities, particularly the private healthcare sector, that fail to report or furnish false data should be strictly penalised.

In conclusion, it is fairly common knowledge that health is not equivalent to hospitals – more so in the context of public health, which is at the interface of numerous social determinants of health. The COVID-19 pandemic and subsequent unplanned lockdown has hurled the harsh truth at us about exactly how precarious these social determinants are for the majority of the country’s population.

Sadly, the seriousness of this seems to have passed by the Government of India, which continues to doggedly position corporates as their primary stakeholders, losing another opportunity to foreground social justice and equity into apportioning resources of the country. India is yet to be blessed with a government that locates its poorest and most vulnerable at the very heart of its policy-making. – The Wire

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