Banjot Kaur 
New Delhi: J.P. Nadda took charge on Tuesday (June 11) as the health minister of the country. This is his second stint in this capacity. The outgoing health minister, Mansukh Madaviya, was at the helm of affairs for three years from July 2021. He passes on the baton to Nadda with many challenges to deal with. While almost none of these issues were part of the electoral discourse of the ruling party, they did not get much traction from the Opposition either. But these issues concerning health affect every household in the country one way or the other.
Here we discuss five such challenges:
Healthcare financing: Even after several reports and committees suggesting the health budget as a percentage of GDP has to go up, it still stands at 1.3% – one of the lowest in the world. As per the interim budget presented for FY 2024-25, the amount allocated to the health sector, though appeared as increasing in nominal terms, actually decreased by 3.17% compared to previous year when adjusted with inflation. Clearly, this was contrary to what the National Health Policy, 2017 made by the Narendra Modi government, recommended. It said the budget allocation had to constantly go up to reach the target of 2.5% of GDP being spent on healthcare, in a ‘time-bound manner’.
A high-level expert group formed by the Manmohan Singh-led government preceding the BJP government had set the deadline for 2017 for this target.
It is not difficult to understand that if the government expenditure on health remains very low, the out-of-pocket expenditure (OOPE) will be among one of the highest across the world. The OOPE is the expenditure which people incur on their own for accessing healthcare.
Out of the total healthcare expenditure of the country, the majority is contributed by the people themselves (52%) as against the state and Union governments (35.3%). The share of the state governments is higher than that of the Union government.
The cliche goes that a family is just one episode of serious illness away from poverty. A Niti Aayog report confirms this. It says 7% of India’s population — about 10 crore people — are pushed into poverty every year due to the amount of money they spend on healthcare. This may be temporary poverty and some may come out of poverty too, depending on their income.
The government’s principal intervention on reducing healthcare spending is an insurance cover of Rs 5 lakh provided to each eligible family per year for hospital admission under the Ayushman Bharat Scheme.
A serious limitation of this scheme is that it is restricted to in-patient department (IPD) and doesn’t provide any assistance for seeking OPD services, while the latter comprise 40-80% of healthcare services.
A recent Comptroller and Auditor General (CAG) report said the scheme was riddled with massive corruption at different levels of service delivery.
***
Nutrition: It is one of the most important social determinants of health.
The last Global Hunger Index report ranked India at 111 among 125 countries by taking into account undernutrition across age groups, stunting and wasting in children and under-five mortality among children. India did worse than some of the poorest African countries. No wonder the previous Modi government rejected the findings though the report makers asserted that the government’s objections with methodology were not founded on facts.
There are several other reports which speak about the ‘epidemic of hunger in India’. The SOFI-2023 report said as much as 74.1% of the Indian population is unable to afford a healthy diet. This level of hunger leads to another problem — these people are more prone to fall ill.
On one hand, people don’t have money to buy adequate food, and on the other hand, they become sick due to no or partial access to a healthy diet. And then they have to spend on buying healthcare services too. This becomes a vicious cycle because money spent on healthcare may again constraint their purchasing power to have a healthy diet.
Also read: In ‘Viksit Bharat’, Budget for Health and Nutrition Declines in Real Terms
The government has various schemes to address the challenges of hunger like distributing five kgs of free ration to about 80 crore families, but it would still not be adequate to be called a ‘balanced diet’ even according to the ICMR’s dietary guidelines issued recently which talk of inclusion of fruits, variety of vegetables etc.
***
Medicines and the twin challenges of access and quality: India has one of the highest out-of-pocket expenditure in the world. One of the biggest contributors to this abysmal trend is the money spent on buying medicines. In other words, out of all services/products bought under the umbrella of healthcare — diagnostics, doctor consultation, related non-medical costs, other medical costs and medicines — it is on the drugs that people spend most of their money — thus revealing inadequate access to medicines.
During Prime Minister Modi’s first term, the government had launched Pradhan Mantri Jan Arogya Yojana (PMJAY) in 2018 — a scheme mainly funded by the Center and partially by the state governments — aimed at providing drugs to people at affordable rates. According to the government, there are about 10,000 PMJAY stores in the country which is definitely a substantial rise from the preceding Congress government.
And yet, independent assessments reveal that a lot is needed to be done, in reality. According to a 2022 survey of Center for Monitoring Economy and Center Pyramids Household, Indians spend 45.5% on buying medicines — out of all services — accessed as part of healthcare. This is the highest proportion of money of the entire pie.
The other issue which should concern the new minister is an imperfect drug regulatory mechanism. In the last two years, many international controversies surfaced on toxic drugs supplied by Indian manufacturing units leading to deaths of several children. After denial of culpability in the case of Gambia and acceptance in case of Uzbekistan, the government decided that all the medicines to be exported would undergo mandatory testing at government labs.
However, such a rule was restricted to medicines sent to other countries. It is not clear why the same yardstick is not applied for medicines supplied within the country. In India too, there are at least two documented incidents — this and this — in which children died due to consumption of toxic cough syrups in the recent past.
Followed by the international controversies, the drug regulator also started what was termed ‘risk-based’ inspections. One reply given in Parliament stated 261 manufacturing units were inspected. The licences were suspended or cancelled — among other things of 200 units.
However, the reply didn’t say a number of things like which were these units and to which companies they belonged, criteria of selection of inspection etc. There was a lack of transparency about this move.
***
Deadlines (some missed and some impractical): The government has dedicated programmes for a few diseases aiming for their elimination. One of them is Kala-Azar. From the earlier deadline of 2017, it was revised to December 2020. The elimination target is less than one case per 10,000 population in every block of the country for three consecutive years, according to the WHO. In 2023, 595 cases were recorded, according to a government data portal . These many cases brought India closer to reaching the target of elimination for the first year. However, a section of the media has presented facts underlining that India has achieved the elimination target already while the WHO certification would come only after two years.
Interestingly, the BJP manifesto for the recently concluded election stated that the efforts to eliminate Kala Azar, among other diseases, would be intensified.
Another such disease is filariasis. It was to be eliminated by 2015 with an extension given upto 2021. Now, the deadline stands revised at 2027. The data available on the National Vector Borne Disease Control Programme (NVBDCP) website suggests 339 districts in 20 states and union territories have been reporting the filariasis cases.
Both Kala Azar and Filariasis come under the category of ‘neglected disease’.
The most ambitious deadline the government has set itself is TB elimination by 2025. India has the highest TB burden across the world.
The country has reported acute TB drug shortages frequently since last year. Even this year, such reports surfaced from different corners of the country. This is the major roadblock as skipping doses can lead to reversal of milestones achieved for an individual patient.
The second hurdle is regarding those TB cases in the country which get ‘missed’ or don’t get recorded in the official records — and hence don’t receive TB treatment. As per the latest World TB report, 10 countries account for more than 70% cases being missed. India is the top contributor with 18% of such missed cases.
A landmark study published from India in The Lancet reported that good nutrition reduced the incidence of TB by 39-48% in the contacts of confirmed TB cases. However, the Indian government provides only Rs 500 per month to each person suffering from TB for nutritional support — something that is highly inadequate.
Due to these, and several other reasons, it is believed that it is nearly impossible to eliminate TB from India by next year.
***
Inadequate infrastructure, human resources: The Modi government claims that it has opened more than 300 medical colleges across the country and added several thousand seats. However, inspections by the National Medical Commission (NMC), the regulator for medical education in India, revealed that 80% of medical colleges examined by them don’t meet the minimum standards. They lack adequate number faculty members as well as infrastructure that a medical college should have
Prime Minister Modi has on several occasions referred to the fact that his government has opened 17 new AIIMS-like institutions in the country. However, parliamentary replies revealed that not one of them was ‘fully functioning’. Former health minister Madaviya said last year in the the parliament that all these institutions were at various stages of operationalisation and were offering limited OPD and IPD (In-patient department) services.
The government also takes pride in the fact that it has built 1.5 lakh ‘health and wellness centres’ — some of them by modifying the existing primary health centres and community health centres (CHC), however, the lack of human resources, including shortage of specialists like gynaecologists, paediatricians, surgeons and anaesthetists, at CHCs mar the rural healthcare facilities, according to the last edition of Rural Health Statistics.
***
While the above five issues may come across as priorities of the new health minister, he would also have to deal with ‘data drought’ which may not come under his ministry but the absence of numbers would seriously affect the healthcare policymaking. These include Census, all-cause mortality data (last released in 2019; it would have helped in confirming or rejecting WHO’s excess death estimates on Covid-19), withdrawal of Health Management Information System (HMIS) data from the public domain and not conducting a couple of sample registration systems (SRS) surveys. The Mandaviya-led ministry unceremoniously removed the director of International Institute of Population Sciences, K.S. James, after the fifth round of National Family Health Survey, which was conducted under his leadership, revealed some uncomfortable figures for the government — questioning the success of its policies.
Good governance on all these issues ultimately become prerequisites for what is described as the ‘Right to Health’ for common people. Such a right would ensure a guaranteed provision of healthcare services to all the citizens and absence of which could be challenged in the court of law. Currently, such a right is not enshrined in the Constitution.
It would be interesting to see if the Nadda-led ministry would take steps to see this progressive right become a reality and, thus, preventing millions of Indians from being pushed into poverty every year.