Healthy trend

The Budget 2022-23 has come under some criticism for not maintaining the recent increases in health allocations. The figures need to be placed in perspective. The Budgetary outlay of ₹83,000 crore for 2022-23 is 16.5 per cent over the budgetary allocations for 2021-22 (₹71,269 crore) and 0.1 per cent over the revised allocations of ₹82,920 crore for the current fiscal. The revised estimate reflects a one-time Covid vaccination cost, which is likely to be considerably less in the coming fiscal, as over 75 per cent of the eligible population is fully vaccinated. A 16.5 per cent rise over the BE for this fiscal is a more realistic comparison to make. While it can be argued that this hike is inadequate in relation to health infrastructure needs, the fact is that Central budgetary spends towards health have more than doubled since 2014-15, when ₹30,626 crore was spent. That said, a flat outlay of ₹6412 crore for Ayushman Bharat for 2022-23 is a disappointment.

The Fifteenth Finance Commission echoes the National Health Policy 2017 to assert that public spending on health should account for 2.5 per cent of the GDP — 1 per cent by the Centre, 1.5 per cent by the States. The Economic Survey (ES) 2021-22 observes that in keeping with the NHP’s goal of 2.5 per cent, “Central and State governments’ budgeted expenditure on health reached 2.1 per cent of GDP in 2021-22, against 1.3 per cent in 2019-20.” Total expenditure by the Centre and States has increased from ₹2.43 lakh crore in 2017-18 to ₹4.72 lakh crore in 2021-22 (BE). However, this spike could largely be on account of the Covid emergency. This level should become a norm, as enshrined in the NHP. The World Bank, however, points out that higher devolution under the 14^th FC has translated into social sector spends by States, a trend that should continue under the 15^th FC period till 2026. The NHP mandates that States should spend 8 per cent of their outlays on health, against just over 5 per cent at present (FC estimates for 2018-19). As for the Centre, its budgeted outlay for 2022-23 is just 0.3 per cent of GDP, a pre-Covid level. Health spending is about lifting all boats, and looking beyond the Central budget.

The focus on allocation should be accompanied by an emphasis on design of schemes, implementation and outcomes. That outlays do not always translate into great outcomes are borne out by the fact that ‘forward’ States such as Andhra Pradesh, Telangana and Maharashtra spend below the national average of 5.18 per cent of GSDP, whereas Jharkhand, Chhatisgarh, Odisha and West Bengal spend above the national average. Serious concerns, for instance, have cropped up over accountability in a number of central and/or State schemes, where the auditing has been outsourced to private entities and details do not figure in official documents. The proliferation of ‘schemes’ has led to lack of accountability. The 15^th FC emphasis on developing primary health care centres, with targeted grants to the local governments, should be accompanied by a participatory audit system in place. Health spending must be viewed through a qualitative lens.