What is remarkable about the Budget 2008-2009 (1) as far as health care is concerned is that there is nothing remarkable about it. It continues the pattern that has been set in place for well over four decades now, of providing schemes which at best can be called hoodwinking the people. Thus government spending on health as a proportion of gross domestic product (GDP) will remain about one per cent (central and state), well below the promised three per cent of the GDP (mentioned in the National Health Policy) and the five per cent suggested by the World Health Organization. This year we see some increase in allotment to the National Rural Health Mission and some noise about a similar urban mission, to list two of the pick and choose proposals. When the outlays are adjusted for inflation, it is a moot point whether there will be a marginal rise or, in fact, a fall. What is clear is that very little has changed.

If one of the duties of the government is to provide health services, we should ask whether the government is fulfilling this duty.

There is no sign in the health proposals of this government — just as there was no sign in the proposals of most governments before it — of a plan aimed at tackling the terrible morbidity and high mortality which is the fate of vast sections of our populace. On the contrary, the government’s health policy and budget are driven by the interests of the health care industry rather than the rights and needs of its people.

The current situation in our country is that we are in the top ten where almost any communicable disease is concerned. At the other end of the spectrum we have also become world leaders in chronic diseases like diabetes mellitus, hypertension and coronary artery disease.

If we consider prevention and treatment as two sides of the same coin, it is clear that we need comprehensive programmes to reduce malnutrition, provide safe water and other such measures which are considered public health engineering (2) as well as a network of public health care facilities to provide effective treatment.

Soon after independence a network of primary health care centres, taluk hospitals, district hospitals and medical college hospitals was put into place. Some states like Tamilnadu and Kerala did better than the rest, but nowhere has this system been really successful. The reasons are many, but foremost of them is that the government has not been committed to make the system truly effective by providing sufficient money and managerial input. Instead, starting as long back as the 1960s, it has encouraged the private sector through various concessions to take the place that should be played by the public sector By the 1990s the system was near defunct.

This is in line with the recommendations of the World Bank in its 1993 World Development Report, Investing in health care (3). The report advocated that the government restrict its provision of health services keeping in mind the following three questions: is it cost-effective? Will people pay for it if the government does not? And will people misuse it if the government provides it? In other words, health care is not a right, and access to health services is determined not by people’s needs but at least partly by what they will or will not pay for. Using this argument, the Bank made the recommendation that the government should provide only five basic preventive interventions. This was truly a tragicomedy in a country were 80 per cent of spending on illness was already private money. All governments since then have been only too eager to embrace this recommendation of the pundits. As a result, a large section of the population is being impoverished by health care spending. It is reported to be the leading cause of rural indebtedness (4).

It is important to note that the only significant proposal in the budget is the five-year tax holiday for hospitals in all but seven metropolitan areas. Not only is this a statement that the government abdicates its responsibility to provide hospital-based care in these areas, it will not increase people’s access to health care. It will be immensely profitable to the corporate sector in health care. Finally, it is in line with promoting health care as a source of profit rather than as a service.

It is no surprise that budgetary allocation for health still hovers around one per cent of GDP, in spite of successive governments promising to raise it to three per cent. This meagre amount cannot be the basis of any far-reaching changes in the way people gain access to and use health care. Therefore, for the foreseeable future, people will pay for health care from their own resources. What this means is a near absence of any except the most urgent interventions for the majority and a few sanitised facilities where those who can afford it will get treatments which they may not need — simply so that all the expensive equipment will be paid for. India will continue to host the cruel paradox of not providing very basic medical care for vast sections of its population, while offering world class facilities to the so-called medical tourists.