Banjot Kaur 
New Delhi: The Economic Survey 2024-25 tabled in parliament on Friday (January 31) highlights many achievements of the Union government in the health sector. Although some of those achievements can be questioned, the biggest problem in the health sector that the Survey has been upfront in focusing on is the lack of quality medical education and the skewed distribution of doctors in the country.
In a rare instance, an Economic Survey has touched upon this issue. It states that despite several measures that were aimed at regulating the fees charged by private medical colleges, one may have to cough up Rs 60 lakh to Rs 1 crore for an MBBS course.
This is significant because 48% of all MBBS seats are in the private sector. No wonder every year a number of seats are left vacant.
The Survey also does not hesitate from stating that despite several measures the National Medical Commission has taken to ensure that medical colleges impart quality education, gaps continue to exist.
“Despite the elaborate regulations and monitoring, issues like shortage of faculty, ghost faculty, low patient load in hospitals continue to affect the quality of training,” the Survey said.
Low patient loads deprive budding doctors of ample exposure to a range of illnesses.
On the other hand, exorbitant fees lead to a situation where every year, thousands of students go abroad to around 50 countries, especially those with lower fees such as China, Russia, Ukraine, the Philippines and Bangladesh.
When these foreign medical graduates return to India, they face difficulties in getting their skills standardised so they can receive permission to practise medicine. Often, this results in court battles, says the government in this document.
The Survey also highlights that though India has nearly attained the patient-to-doctor ratio prescribed by WHO standards, some distance still needs to be covered.
As many as 1,263 patients are dependent on one doctor, while the WHO prescribes that there should not be more than 1,000 patients per doctor.
There are 13.86 lakh practitioners of modern medicine registered as of July 2024, according to the Survey.
However, what is problematic is the skewed distribution of doctors and health centres. The Survey estimates that 75% of dispensaries and 60% of hospitals are in urban areas, where 80% of doctors serve. This leaves rural areas severely deprived of good-quality healthcare.
For every 3.8 doctors present in urban areas, there is only one in rural areas – where more than the 70% population of the country lives, according to the Survey.
However, what compounds the problem – which is often not discussed in official documents – is the absenteeism of doctors.
So on the one hand, the number of doctors serving in rural areas is fewer than necessary, but even those deployed there are on many occasions not found serving.
This worrying trend adversely impacts the achievement of the government when it claims that it has built more than 1.75 lakh health and wellness centres.
The onus of ensuring the availability and presence of doctors is largely on the state governments.
Health expenditure and infrastructure
The Economic Survey gives various figures in absolute numbers to state that spending in the health sector has gone up and that out-of-pocket expenditure has come down.
The key indicator to assessing health funding is its percentage in the total GDP. Referring to the last edition of the ‘National Health Accounts (NHA), which is for 2021-22, the Survey states that 1.84% of the GDP is spent in the health sector. The corresponding figure for 2020-21 was 1.6%, per the NHA released for that year.
The NHA for 2021-22 were released this year. These reports are usually delayed because of the procedure involved in making them.
In this year’s Economic Survey, the government while presenting the health spending-to-GDP ratio has departed from a practice it used to follow in Economic Surveys presented for the previous years. In them, the health budget allocation also included some of the allocations made to the water and sanitation department. Critics often questioned this move as it masked the government’s real expenditure on healthcare.
This year, however, the government has made a correction and sourced its data from the NHA, which excludes the money spent on water and sanitation, thereby revealing the actual expenditure solely on healthcare.
Therefore, it would not be prudent to compare the health spending-to-GDP ratio in this year’s Survey with previous ones.
The National Health Policy 2017 had stated that expenditure on health must rise to 2.5% of GDP – a goal which seems clearly elusive now.
The government made several claims about improving health infrastructure in the Economic Survey.
One of its key flagship schemes for this purpose is the PM-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM). This was launched in 2022 with an outlay of more than Rs 60,000 crore and with the aim of strengthening multiple pillars of healthcare.
These pillars are urban health and wellness centres, critical care blocks, integrated public health labs, block public health units and building-less sub centre-health and wellness centres.
PM-ABHIM is a ‘centrally sponsored scheme’ (CSS). Therefore 60% of its funding is given by the Union government, while the rest comes from the state governments. For the northeastern states, the Union-state funding ratio is 90:10.
Its target was to build a certain number of these pillars. This was to be achieved by 2026.
The Union government has already achieved the deadline by approving the construction of the number of units that were aimed for, indicates the Survey.
However, at least two parliamentary reports in the last two years have indicated that state governments failed to fully utilise their budgets under the PM-ABHIM scheme due to the long ‘gestation period’ taken in making these units functional.
“Utilisation/expenditure under the scheme was low in FY 2022-23 as components under the scheme primarily pertain to infrastructure/capital works which require long gestation period before grounding due to challenges on account of encumbrance free site identification/selection, multi-locational nature of sites/units under the scheme, delays in finalisation of implementation agency etc,” the 2024 report stated.
The 2023 parliamentary report had flagged almost the same issues with the implementation of the scheme.
Another important step that the Union government had taken was to create 157 new medical colleges in the country to improve its health infrastructure. However, this CSS scheme doesn’t find a mention in the Economic Survey.
The 2024 parliamentary report stated that only 94 medical colleges under this scheme were functional as of February 2024. The primary bottleneck with these schemes is the same as what is true about other CSS schemes — underspending or not utilising the money that they get from the Union government.
The 2024 committee report noted that the Union government had ensured the disbursal of funds in a timely manner, but that state governments were not able to do their bit adequately. For example, some delayed submitting detailed project reports and/or did not properly utilise funds.
Lifestyle disease and mental health
Non-communicable diseases (NCDs) also find an elaborate presentation in the Economic Survey.
Common NCDs that are loosely referred to as ‘lifestyle diseases’ are cardiovascular disease, hypertension, diabetes, cancers and chronic respiratory disease.
The government in the latest Survey claimed that its National Programme for Prevention and Control of NCDs “has significantly strengthened healthcare infrastructure, decentralising services and ensuring quality care reaches rural and remote areas”.
However, a recent study in The Lancet reported that less than one-third of Indian men and women suffering from diabetes had received treatment. It also said that treatment coverage had barely improved in the last 44 years.
India has been the diabetes capital of the world for a very long period now and 30% of untreated cases also come from it.
Like in the previous Economic Survey, mental health has been given special attention this year, too. As many as four pages have been devoted to it this year.
A day after the Economic Survey was presented last year, the government decreased the allocation to the ‘National Tele Mental Health Programme’ – a key intervention – in the budget presented for FY 2024-25. The outlay for this programme for 2024-25 was Rs 90 crore. This was Rs 40 crore less than the outlay in the budget presented in FY 2023-24.
It would be interesting to see if the budget for the next FY matches the urgency to provide mental healthcare services which the latest Economic Survey displayed.
One reason for the reduction last year could have been that this Union government scheme in FY 22-23 could utilise only half of the amount allocated to it.
The Survey has also spoken about the air pollution that kills millions every year and is responsible for a number of diseases that affect the body from head to toe.
The government has simply named the various initiatives it has taken to combat air pollution. However, it stopped there and presented no forward-looking recommendations to address this worsening annual problem.