The two areas of the Union Government expenditures on health care are curative and preventive. Let us consider the curative first. According to the National Health Accounts Estimates for India, 2018 published by the Ministry of Health and Family Welfare (MoHFW), the Government spent Rs 9,134 crores in 2015-16 on the 31 lakh Government employees; or about Rs 7,000 per person if we include their families. In comparison, the expenditure on the non-Government citizens was Rs 38,794 crores on 131 crore persons or a meager Rs 296 per person. This includes expenditures on Government-financed health insurance. The primary objective of MoHFW has, howsoever unwittingly, become to serve the Government employees and, by default, not the public.
Secondly, in the Budget for 2020-21 MoHFW, which promotes the allopathic system of medicine, has been allocated Rs 63,000 crores; while the Ministry of AYUSH, which promotes alternative systems like Ayurveda and Homeopathy has been allocated a meager Rs 2,100 crores. No doubt the allopathic system is doing a great service to the country by brining certain cures such as placing stent in the heart that are not available in the AYUSH system. At the same time, the AYUSH system is more oriented at providing systemic treatments. Thus, while MoHFW provides cure for the heart patients replacing one stent with another; the Ministry of AYUSH prevents the need for a stent. Yet the Union Government allocates more money to cure and less to prevention. The reason for this lopsided allocation appears to be that Multinational Health Companies (MNCs) supply the instruments and medicines that are promoted by MoHFW.
Thirdly, within the MoHFW budget there is a lopsided allocation in favour of hi-tech treatments like stents that are called “tertiary,” and less on primary and secondary treatment. In a paper titled “Health Care Financing Reforms in India” published in 2012, Govinda Rao of the National Institute of Finance and Public Policy has pointed out that the National Health Policy had placed a target of 10 percent expenditures on tertiary care but the actual is 28 percent. Once again, the MNCs are the beneficiaries of these expenditures.
Fourthly, as pointed out by Govinda Rao, most of the Government health expenditures are used up in paying salaries to Government health workers. I have not been able to access the share of salaries in the health expenditures of the Union Government, however, the share was 83 percent in Madhya Pradesh and Orissa.
One step towards the correction of these anomalies in MoHFW, as suggested by advisor to Niti Ayog Rakesh Sarwal, is that the Central Government Health Service should be converted into a Universal Health Service so that the expenditure on Government employees and people becomes equal. The second step is to increase the allocations of AYUSH and reduce those of tertiary treatment. The third step is to fix a maximum ratio of salaries in the health budget and, in case of a budget crunch, reduce the salaries of government health workers. No purpose is achieved by paying them salaries without any medicines to dispense and beds to treat.
The second area of our health system is preventive care which includes vaccinations. A problem here—in respect of Covid—is that the virus is changing rapidly. Therefore, a vaccine against Covid of yesterday may not be effective against Covid of tomorrow. Another problem is that the performance of our preventive health within MoHFW is unsatisfactory. Govinda Rao says that the only seven percent children do not get measles’ vaccination in South America against 30 percent in India. I think MoHFW will not be able to deal with Covid by the vaccination route for both these reasons.
The second issue in preventive care is our people need to change their lifestyles like partaking of garlic, giloi, ginger and turmeric; undertaking yoga and meditation; and getting more exercise and sunlight. The MoHFW has successfully launched campaigns in favour of iodine-laced salt and breast feeding of infants. A similar campaign can be launched by Ministry of AYUSH for promoting above mentioned changes in lifestyles; and, perhaps, providing free packets of garlic, giloi, ginger and turmeric to every household.
As said above, the total expenditure of the Union Government on health of non-Government citizens was Rs 38,794 crores in 2015-16. Of this only 12,000 crores were made on preventive health which included vaccination; information, education and communication; anti-smoking campaign; free distribution of masks; and testing for diseases like Covid, diabetes and cancer. The Government must increase these expenditures drastically and cut those on hi-tech tertiary treatment. Such a measure will improve the immunity of our people, reduce the spread of Covid and ultimately reduce the burden on MoHFW for providing curative care.
The third issue is to explore a different social paradigm. A paper by Vaidya Vachaspati Tripathi published on the Uttar Pradesh Government website says that taking bath in the rivers in during the Kumbh leads to development of immunity. Large numbers of pilgrims spread miniscule amounts of various disease-creating viruses and bacteria in the water. These enter the bodies of other pilgrims during the dip and prompt the body of the healthy pilgrim to fight these viruses and bacteria and develop immunity. In his words, as told to me, “one dip is sufficient for good health till the next Kumbh.” Such festivals lead to community transmission of immunity just as we fear community transmission of the Covid virus. Subject to advice from the AYUSH Ministry, the Government can announce a particular day when all citizens may be requested to take a dip in their nearby river or pond. The transmission of miniscule amounts of Covid virus can develop collective immunity.
The main difficulty in implementing these measures is the interests of the MNC suppliers of hi-tech curative medicine and the well-meaning and, at the personal level, very kind team of doctors who unwittingly get focused on treating the individual high income patients not realizing the resulting exclusion of the majority. The MoHFW is focused on eating the dessert not realizing that the body will collapse without nutritious dal and roti.
The Covid pandemic is not going away anytime soon. We certainly need to provide curative treatment to those affected but even more we need to put in place preventive measures of a campaign to effect a change in lifestyles, free distribution of garlic, giloi, ginger and turmeric and developing creative solutions like community bath as is done during the Kumbh and as was perhaps doe in the Great Bath of Mohenjo Daro. The doctors treating Covid patients are forced to make a choice between who will live and who will die. The choice before the Government is whether the few will live and many will die?
(The author is formerly Professor of Economics at IIM Bengaluru)