However, that seems to be still a far-off goal. The first few years of this decade were spent in fighting the global pandemic and then resolving legacy issues left behind by the COVID-19 spread.  

By the middle of 2022, India recorded more than half a million deaths due to the novel coronavirus. Official estimates reported 4.81 lakh COVID deaths between January 1, 2020 and December 31, 2021. However, the World Health Organization (WHO) estimates put the death toll at nearly 10 times the official estimate.

WHO experts calculated excess mortality that included deaths associated with COVID-19 directly or indirectly (due to the inadequacy of a crumbling health infrastructure under pandemic pressure). This resulted in a sharp reaction from the Government of India, which outrightly rejected these external independent estimates of COVID-19 deaths.

While 'fights' over the death toll went on for some time, quite a few health experts hoped the pandemic's aftermath would see a rising focus on basic health infrastructure and result in requisite increases in government expenditures.

However, as real-time data and information confirm now, those were false hopes.

India’s post-pandemic budget expenditures are now back to normal low levels. Even those comparatively lower budget allocations are not fully spent. The public memory is too short and the public health discourse in the country has gone back to “business as usual”. The economic and budget documents of the current year bear testimony to that.

The word ‘health’ was mentioned just 4 times in the budget speech. And that too in generic ways clubbed with other social welfare phrases. Not mentioning health specifically perhaps underlines the shift in focus away from the healthcare sector. Barely two years after surviving “a pandemic of the century”, this is an unfortunate development for the entire nation.

The Economic Survey 2023-24 correctly noted the issue and said, “For India’s working-age population to be gainfully employed, they need skills and good health”. But strangely the document then went on to blame the evolving food habits of certain sections of the population for deteriorating health conditions in the country.

The survey said, “Social media, screen time, sedentary habits, and unhealthy food are a lethal mix that can undermine public health and productivity and diminish India’s economic potential. The private sector’s contribution to this toxic mix of habits is substantial, and that is myopic”.

This strange and weird accusatory logic succinctly depicts the current state of affairs in public health.

Health Spending Falls Way Below Policy Target

When the new millennium started, India spent 4.3 per cent of its GDP on current health expenditure in 2001, according to the World Bank data. Health spending went down consistently in subsequent years, before rising again to 3.8 per cent of GDP in 2013. After that, it kept on falling again before the COVID-19 pandemic arrived.

The country spent 3.3 per cent of GDP on health in 2020 and 2021. In contrast, China, South Africa and Brazil spent 5.4 per cent, 8.3 per cent and 9.9 per cent respectively on health in 2021.

With a reasonably well-functioning public-funded National Health Service (NHS), the UK allocated 11.3 per cent of GDP to health in 2022 and 12.4 per cent in 2021. Though a threat of budget cuts hangs over the UK's NHS, the decade before the pandemic saw the country consistently spending close to 10 per cent of its GDP on health.

Meanwhile, India’s health budget allocation declined from 2.3 per cent of the total budget in 2019-20 to 1.9 per cent in the 2024-25 full budget. Even during the peak pandemic years of 2020-21 and 2021-22, health allocation in the budget remained below 2.3 per cent of total budget expenditure.

National Health Policy 2017, published by the Ministry of Health and Family Welfare, recommended increasing health expenditure to 2.5 per cent of GDP by 2025. Immediately after the pandemic, a National One Health Mission was also launched, to achieve overall pandemic preparedness and integrated disease control. However, continuously falling budget allocations are not commensurate with these aspirations.

Allocation on health in the current budget has gone up by a meagre 0.4 per cent, compared to 2023-24 allocations. If adjusted with inflation, the health budget has shrunk in real terms.

What is alarming is that even these dwindling allocations are not fully spent. In 2022-23 around Rs 13,000 crore and in 2023-24 close to Rs 10,000 crore of budgeted health allocations were unspent.

There can be numerous (fair or unfair) reasons for this non-utilisation. That is why budget impact assessment of central health schemes is necessary. Such assessments can measure the efficacy of certain schemes, based on which decisions to continue or discontinue schemes can be taken.

Nutrition, Not Health Infra, Gets More Allocation

If we look at the outlays for major schemes, then almost all the allocations either remain the same or have increased slightly in absolute terms. Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PMABHIM) allocation remains nearly the same. The flagship Swacch Bharat, both rural and urban, gets the same allocation as last year.

It seems creating health infrastructure is not a priority any more. The largest amount has been allotted to the flexible pool for RCH (reproductive and child health) and Health System strengthening, National Health Programme and National Urban Health Mission.

This is the only allocation that has increased substantially by 30.3 per cent compared to last year’s budget. However, this is an umbrella fund. It will not necessarily be utilised exclusively on health infrastructure.

Saksham Anganwadi and POSHAN 2.0 allocation are the next largest, followed by PM-POSHAN. In both these schemes, absolute allocations increased albeit marginally. However, all these belong to the ICDS (Integrated Child Development Services) silo. Existing nutrition programmes, therefore, seem to be the priority.

Health No More A Priority?

The Union Budget of FY20 unveiled the Social Stock Exchange (SSE) to facilitate private finance for the social sectors and welfare. Consequently, the National Stock Exchange (NSE) and Bombay Stock Exchange (BSE) obtained SEBI’s (Securities and Exchange Board of India) in-principle approval to set up a separate segment of SSE.

According to the Economic Survey, 51 non-profit organisations (NPOs) are registered in BSE and 50 are registered in NSE. Nine NPOs till April 2024 have raised a total of Rs 12.4 crore.

This year’s budget could have been the ideal one to give further direction to the SSE and provide needed incentives. But that was again not to be.