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20 November – PLUGGING GAPS IN HEALTH SYSTEM

Recently, the Union government launched the Ayushman Bharat Health Infrastructure Mission (ABHIM), aimed at strengthening crucial public health infrastructure in the country and the first such major initiative since the National Rural Health Mission (NRHM) in 2005. The first announcement was made in the Union Budget in February 2021 by the name of the Pradhan Mantri Atmanirbhar Swasthya Bharat Yojana (PMASBY), with a corpus of Rs 64,180 crore assigned over six years until 2025-26. The central focus of the mission appears to be bolstering of the disease surveillance and epidemic preparedness infrastructure and systems, with reinforcement of medical care facilities being a strong adjunct.

The pandemic has uncovered a plethora of gaps in Indian healthcare, ranging from inadequacies in basic healthcare to misalignments in medical education. We cannot address all of them on an immediate basis. Rather, what is needed is a sustained set of well balanced, well-timed, and well implemented priorities. While the horrors of Covid-19 don’t necessarily predispose us to another such catastrophe in the immediate future, the emphasis on disaster preparedness and disease surveillance is timely and opportune.

While infrastructural gaps could be addressed in mission mode, sustained funding and attention are crucial for such structures to thrive and function optimally in the long run. The fresh infusion of structures, inputs and systems that the ABHIM envisions would entail the states and the Centre to consistently, commensurately and multi-dimensionally increase public health expenditure in the upcoming times. The current allocation for the mission is less than half a per cent of the GDP, spread over six years. There is a lot to learn from the past experiences of similar initiatives. For instance, when the NRHM was launched, public health expenditure was envisioned to increase to about 2-3 per cent of the GDP by 2012, which however remained at around 1 per cent. The Centre was supposed to increase funding by 30 per cent in the first two years after launch and 40 per cent thereafter until 2012. Similarly, states were to increase their own allocations by providing matching contributions. However, these were hardly realised, and evidence has demonstrated an undesirable ‘substitution effect’ of Central investments upon states’ own allocations for health.

 It will take us to live up to the National Health Policy’s (2017) commitment to increase public health spending to 2.5 per cent of GDP by 2025, as unrealistic as the target might seem today.

The Centre has done the right thing by taking the first step and spearheading the mission, given particularly the prevailing inter-state disparities and the weak financial position of many states. Similarly, we need to learn from the several challenges that bogged down the Pradhan Mantri Swasthya Suraksha Yojana, which aims to reduce regional imbalances in tertiary healthcare by building new AIIMS and upgrading existing government medical colleges.

Secondly, we must remember that a lot will be left to be desired in terms of holistic and horizontal strengthening of the Indian public health services, despite the ABHIM. One of the biggest weaknesses in Covid-19 response has been the lack of a horizontally strong general health system, given the predominance of vertical health programmes that have traditionally fragmented the Indian public health services.

Tertiary and critical care needs, though overwhelming, were conspicuously fewer during the Covid-19 pandemic, and much of the pandemic response rested on the continuum of general primary and secondary healthcare services which will only be limitedly addressed by the ABHIM. It will be necessary to ensure that much like the other vertically oriented programmes, the ABHIM doesn’t deprive other important areas of their rightful attention and investments. This is particularly important given our poor track record with things that cannot be addressed in mission mode.

Finally, much of the success of the ABHIM will depend on its effective coordination with other programmes with which it shares multiple overlapping components. For example, the National Health Mission is the flagship programme in primary healthcare in the country; the Pradhan Mantri Jan Arogya Yojana aims to increase access to secondary and tertiary hospital care; the National Digital Health Mission aims to lay an all-embracing digital health infrastructure, and so on.

 A multiplicity of such programmes, if not functioning with sufficient coordination, can risk redundancies, duplication and wastefulness. Effective coordination between multiple departments and sectors will be crucial to ensure that the diverse inputs required to drive the newly laid infrastructure are in place, as also to effectively tap the many opportunities that may arise out of this mission, such as enhanced facilities to train public health manpower. 

(GS Paper-2 / Governance / Health Sector)

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