As the Narendra Modi government’s first Budget following the Covid-19 pandemic, it came as no surprise that it would focus on health. But the headline that caught everyone’s attention was the announcement by Finance Minister Nirmala Sitharaman of a whopping 137 per cent increase in allocations for health and “well-being”— from Rs 94,452 crore last year to Rs 2,23,846 crore for the financial year 2021-22.
Half of these additional allocations are primarily driven by four things: Rs 35,000 crore for vaccination; nearly Rs 40,000 crore for the Jal Jeevan Mission (a rural drinking water scheme to provide functional tap connections to every household); grants for local bodies through the Finance Commission for water and sanitation; and Finance Commission grants for augmentation of health infrastructure.
On the face of it, a holistic approach to health that covers nutrition and water, is a step in the right direction. But this is no ordinary year. The Covid-19 pandemic has exposed several existing vulnerabilities in India’s public health sector, including low investments, and higher demand for vacancies among health workers , inadequate primary healthcare centres and significant inter-regional disparities. In such a situation, the year called for a clearer roadmap on how best India can tackle its weak public health system to mitigate not just the immediate and short-term repercussions of the pandemic but also ensure resilience for the future health needs. Unfortunately, this is where Budget 2021 fails to live up to expectations.
Low direct spending
First, direct spending via the Union Health Ministry continues to be low. After a 24 per cent increase during the current fiscal year to deal with the pandemic, allocations for FY2021-22 actually fell by 11 per cent. In effect, compared to the Ministry’s pre-pandemic budget, there has been only a 10 per cent increase in overall ministry-level allocations.
Similar is the case with allocations for the National Health Mission, which is not just a flagship programme of the Union government with focus on primary health but also a means through which a lot of the emergency Covid-19 expenditure was provided to states. The minimal five per cent increase in NHM allocations even in revised estimates for 2020-21 suggests that most of the expenditure for the year has been done through repurposing of existing funds rather than additional allocations. For the coming year too, we see only a 4 per cent increase in nominal terms. To put this underfunding into perspective, in 2020-21 even prior to the pandemic, the projected demand for the rural and urban arm of NHM was over Rs 60,000 crore. Even with this additional increase, allocations remain 46 per cent lower.
India needs significant investments
With the slowdown in several health interventions, particularly during the lockdown period, getting back to even pre-pandemic levels is likely to require significant investments. The Health Management Information System (HMIS) reveals that between March and April 2020, the number of immunisation sessions held fell by more than half from 9.81 lakh to 4 lakh. Similarly, given India’s dubious distinction of having the highest Tuberculosis burden in the world, the fall in notified cases will require additional resources to actively find and treat missed cases. With NHM allocations not even keeping pace with inflation, it’s unclear how these will be funded.
Nutrition is another area that is concerning when it comes to allocations this year. The presence of a large network of frontline workers in health and nutrition allowed us to quickly mobilise on-ground support. Activities ranged from Covid-19 specific tasks, to doorstep delivery of services, including supplementary nutrition. Yet, several surveys have revealed a gap in the provision of services. Ensuring that all services reach households in a timely manner is going to require filling existing vacancies, ensuring better pay for the frontline workers and provisioning for finances to meet requirements. An analysis done by the Accountability Initiative for 2020-21 found that for supplementary nutrition alone, the total approved budget accounted for only 47 per cent of estimated requirements. In such a situation, the decline in nutrition allocations are extremely worrying.
Finally, a look at water supply and sanitation. A significant increase in allocations for rural water supply via the Jal Jeevan Mission comes after years of low budgeting. At the time of the launch of the scheme, the central share had been estimated at Rs 2.8 lakh crore over five years. At the start of FY2020-21, the Union government allocations were 67 per cent lower than those approved by the Cabinet for the year.
The pandemic presented an opportunity to rethink India’s health strategy. Unfortunately, the Modi government’s Budget isn’t very clear on this.
Avani Kapur @avani_kapur is a Fellow at the Centre for Policy Research and Director of the Accountability Initiative. Views are personal.
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