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Jana Swasthya Abhiyan Statement on Implications of Interim Union Budget 2019-20 for health

The Interim Union Budget 2019-20 reflects a definite push for an insurance-based model of health care, which comes at huge and disastrous costs of the public provisioning of health. In a country like India, where a large section of the population that is poor, vulnerable and dependent on the public provisioning of health care, the consequences of the current budget are catastrophic. They also demonstrate the continuing lack of serious commitment of this Government to health for all.

The scrutiny of the allocation of priorities in the interim budget clearly indicates what the government seeks to achieve.

Under-funded Public Health: Under this government, National Health Mission (NHM) has been continuously neglected in every budget and its share in the total Union government allocation on health has gone down from 61 per cent in 2014-15 to less than half (49 per cent) in 2019-20 interim budget. The allocation under NHM has increased only marginally by about two per cent over 2018-19 RE if one excludes the Health and Wellness Centres (HWCs) component. The Health and Wellness Centres (HWCs), another key component under Ayushman Bharat, meant to expand primary care for Non-Communicable Diseases has received an allocation of INR 1600 crores. This is a mere fraction of what is needed to achieve the goal announced by the government last year: to convert 1.5 lakh Sub-Centres into HWCs. Further and more critically, including HWCs as a new scheme under NHM without making additional budgetary provisions for it, would mean that this money allocated to HWCs would come at the cost of existing interventions under the NHM.

The Government’s apathy towards strengthening the public health system is apparent given that it has reduced capital expenditure by 43 per cent in the interim budget 2019-20 over the actual capital expenditure in 2107-18. This is essentially meant to build infrastructure and procure equipment. Furthermore, the scheme to strengthen district hospitals and medical colleges with more human resources has received an additional allocation of INR 30 crores compared to the previous budget, which, after taking into account 3.4 per cent inflation would mean significant reduction in real terms.

Also, under the head “Establishing New Medical Colleges (upgrading District Hospitals)”, there is a decline of nearly 40% over the expenditure in 2017-18. These reductions are especially harsh in the context of government’s recent announcement of providing funds and land for setting up private hospitals in Tier-2 and Tier-3 cities.

These stagnant and declining allocations put us squarely on track to losing the gains that were achieved through NHM in its first decade. In that earlier period, concerted and increasing emphasis on public sector provisioning helped India improve access to select essential services and this helped us come close to achieving a number of Millennium Development Goals. In the Sustainable Development Goals era, when there is a need to improve access to a much larger range of services, the reduced allocation is a huge impediment

Misplaced Priorities- PMJAY: In the 2019-20 interim budget, the Ministry of Health and Family Welfare (MOHFW) received an allocation of INR 63298 crores, an increase of little more than INR 7000 crores compared to the previous year’s revised estimates. As much as 55% (INR 4000 crores) of this increment in allocation is devoted to one scheme- i.e. the Prime Minister’s Jan Arogya Yojana (PMJAY), which is a government funded scheme to cover secondary and tertiary level inpatient expenses for poor families. While this is a whopping 167% increase in a single year for a single scheme – unprecedented in the health sector – PMJAY essentially incentivises private investment in health care through assured market share, as well as subsidies in the form of viability gap funding under the banner of free hospitalisation for the poor. It is one of India’s biggest public private partnerships. There is a substantial and growing body of evidence that such segmented insurance schemes are ineffective in providing free care, that rather than reducing, they increase out of pocket expenditure, and that they are associated with inappropriate and unnecessary care. When insurance is scaled up in a context where there is a huge inadequacy and inequity in access and an almost complete absence of regulation, it would result largely in transfer of public funds into private hands without any matching health outcomes or financial protection. The current government remains adamant on expanding the scheme.

“Women led” or “Women mis-led”: Although the Finance Minister talked about “Women-Led Development” in his budget speech, the programme/schemes that are relevant for women’s health have been neglected. Allocations towards Reproductive and Child Health (RCH) component under NHM, which also includes schemes like Janani Suraksha Yojana (JSY), immunisation programmes and various key disease control programmes, have experienced a cut of around INR 4200 crores compared to expenditure in 2017-18. The allocations for Pradhan Mantri Matru Vandana Yojana (PMMVY), a scheme for maternity entitlement and wage compensation for women, was cut to half in the previous year’s revised estimate – from Rs. 2400 crores in 2018-19 BE to Rs. 1200 crores in 2018-19 RE – and in this budget an additional INR 1000 crores over 2018-19 BE have been allocated. Not only that the allocations are much lower compared to the requirements, reduction in the allocations for such important programmes as RCH reflects the government’s indifference towards women’s health.

As for the frontline workers, the budget speech mentions a 50% hike in the honorariums of the ASHAs and Anganwadi workers, This is, however, far less than the long standing demand for minimum wages (not less than INR 18,000 per month), along with social security including monthly pensions of not less than INR 3000.

Thus, women’s health programmes, schemes and women workforce have been neglected, ironically just months after India hosted the Partner’s Forum and launched its National Strategy on Women’s, Adolescents’ and Children’s Health (I-WACH)- a document that acknowledged a lot of the issues that remain unaddressed in the budget. It is apparent that the last five years of NDA government have been characterised by a neglect of public health system and primary care on one hand and promotion of for-profit private sector through a series of measures such as PMJAY. It is striking that the Union Government spending on health stands at merely 0.31 per cent of GDP, which is much lesser than what was spent a decade back in 2009-10. The National Health Policy 2017 talks about increasing public spending to 2.5 per cent of GDP by 2025, but this would remain a far cry if the Union Government allocations towards health are not increased considerably every year by at least 30 per cent.

The Jan Swasthya Abhiyan strongly opposes the above in the interim health budget. This budget has reduced health allocations in real terms and will lead to further collapse of public health services while strengthening the discredited ‘insurance model’, despite strong evidence against the effectiveness of such commercial insurance based schemes.

We demand that increased allocations should be in schemes and programmes, which strengthen the public health system, such as the NHM, HWC, or strengthening tertiary care; rather than funding insurance schemes like the PMJAY, which essentially works towards greater privatisation and commercialisation of health care.

We urge the government to follow recommendations for increasing the budget to at least 2.5% per cent GDP as envisaged in the National Health Policy 2017, accompanied by strengthening the public provisioning of health care to ensure adequate supply of free medicines and diagnostics, upgrading of PHCs and CHCs, improving working conditions of the health workforce, community accountability of public health services, strengthened primary health care in rural and urban areas linked with District health systems. These essential steps need to come onto the agenda, to ensure Health and Health Care for all the people of this country.

On behalf of the
Jan Swasthya Abhiyan

Indranil Mukhopadhyay – 9868701429
Sarojini N – 9818664634
Richa Chintan – 9910887838
Deepa V – 9871642320

Addresses for Correspondence:
National Secretariat: c/o SAMA, B-45, 2nd Floor, Main Road Shivalik, N.Delhi – 110017
c/o Delhi Science Forum, Khasra No.275, West End Road, Saidulajab, New Delhi – 110030
Email: [email protected]

5th February 2019

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