Can Investment In Public Health Improve Health In India?

The healthcare landscape in India presents unique challenges and opportunities. Total expenditure on public health in India was 3.6% of GDP in 2019. It was much lower as compared to the United Kingdom, China, and the United States of America which spent 9.9%, 5.4%, and 16.8% respectively in 2019. The impact of inadequate funding on health outcomes in India remains significant. As awareness about health-related issues grows and the demand for better healthcare facilities increases, it becomes crucial to examine the role of the government in addressing these challenges. 

India has been nurturing a progressive vision for public health since the inception of its constitution, thanks to the Directive Principle of State Policy. Incorporated in Part IV of the constitution, these principles have functioned as a roadmap for policy-making, guiding the government toward the realization of a just and equitable society.

The framers of the Indian constitution, led by Dr. Ambedkar drew inspiration from the Irish constitution and believed that the Directive Principles would propel the nation towards its ultimate goal of social, economic, and political justice. Health is an integral component of these principles, with Article 47 of  The Constitution Of India specifically tasking the government with improving public health and providing facilities for disease prevention and treatment.

At a time when prioritizing public health and social justice was not the norm, they recognized the significance of these issues and crafted the Constitution with these concerns in mind. This forward-thinking approach, embedded in the Constitution, showcases the ingenuity of those who shaped India's foundational document.

These embeddings in the Constitution assign the responsibility to the government to ensure healthcare facilities are accessible to all citizens, especially the marginalized and economically disadvantaged. Additionally, they stress upon the importance of enhancing public health, which includes access to healthcare facilities and preventive measures. This duty signifies that the government should take proactive steps to promote public health through awareness campaigns, vaccination drives, and health education programs. The far-sightedness of the framers of our Constitution is a testimony to their dedication to building a progressive and forward-thinking nation.

With healthcare emerging as one of the top three priority areas for Indian voters, it's evident that public awareness of health-related issues has grown, leading to increased demand for better healthcare facilities. While the Constitution has laid the groundwork for public health, it is crucial to understand the contemporary situation in India and the implications of public health spending on the lives of its citizens. 

A report by James Dennison titled "A Review of Public Issue Salience: Concepts, Determinants, and Effects on Voting" highlights the challenges faced by an underfunded public health system in India. The report highlights a bleak reality: an estimated 55 million Indians are living in poverty due to catastrophic out-of-pocket health expenditures. A lack of investment in the public health system compels people to rely on private healthcare services, despite the financial burden it creates.

To further emphasize the significance of healthcare as an electoral issue, the Centre for the Study of Developing Societies (CSDS) and Lokniti conducted a survey called "Democracy and Health in India: Is Health an Electoral Priority?" in five Indian states—Bihar, Gujarat, Rajasthan, Tamil Nadu, and Uttar Pradesh. The survey aimed to understand citizens' perceptions of health as an electoral issue, their experiences with the healthcare system, and the role that health plays in their voting decisions. 

This survey results reveal that 61% of voters believe the provision of health facilities influences their vote choice to some extent or to a great extent. Furthermore, a staggering 80% of voters believe it is the government's responsibility to provide healthcare services. Interestingly, the survey also discloses that 64% of respondents think the Indian government should focus on improving government dispensaries and hospitals, while only 11% believe the government should help people access private healthcare services by providing health insurance.

Governments may exploit the pressing need for healthcare by announcing the construction of new healthcare facilities. However, these facilities often remain understaffed and do not fully satisfy the health needs of the population. Notable examples include many of the peripheral All India Institutes of Medical Sciences (AIIMS).

A 2015 Times of India article revealed that it was fashionable to announce the setting up of new AIIMS in every annual union budget. Despite these announcements, many AIIMS facilities struggled to deliver the promised quality and accessibility of healthcare services. Issues such as acute shortage of human resources, incomplete infrastructure, and construction delays plagued the institutions. For instance, AIIMS Bhopal experienced cost overruns, and it lacked a drainage system, and a functioning central air conditioning system, and only had two temporary water connections.

The article also reported that AIIMS Patna lacked a labor room, blood bank, or emergency services, and had only one X-ray machine but none for CT or MRI. AIIMS Raipur had only 64 faculty members for 24 non-clinical and clinical departments, out of the required 305, and only 200 contract nurses against the sanctioned 1,800 nursing posts. Most institutes lacked super-specialty departments such as cardiology, nephrology, endocrinology, neurosurgery, burns, plastics, or even intensive care units (ICUs). Thus, despite investing thousands of crores in building tertiary care hospitals to treat diseases, the funding for improving health is still insignificant.

Having established the significance of public health spending and its role as an electoral issue, let's now delve into the relationship between budget allocations and health outcomes in different Indian states.  

By analyzing data from the Reserve Bank of India's "State Finances: A Study of Budgets" report, as well as the Ministry of Health & Family Welfare and NITI Aayog's "Healthy States - Progressive India" report, we can examine the dynamic relationship between budget allocations and health indicators from 2014 to 2018.

In 2014-15, Kerala allocated 5.3% of its aggregate expenditure to health, gradually increasing to 5.5% in 2018-19. This consistent investment in healthcare resulted in the best outcomes for two critical health measures: neonatal mortality rate (NMR, the number of newborns dying before reaching 28 days of age per 1000 live births) and under-five mortality rate (U5MR, the number of children dying before their fifth birthday per 1000 live births). Kerala's NMR reduced from 6 per 1000 live births in 2014 to 5 per 1000 live births in 2018, and its U5MR dropped from 13 per 1000 live births in 2014 to 10 per 1000 live births in 2018.

In contrast, Madhya Pradesh's health spending fluctuated from 4.3% in 2014-15 to 3.8% in 2016-17 and back to 4.2% in 2018-19. This inconsistency in investment was mirrored by its poor health outcomes: NMR stagnated at 35 per 1000 live births between 2014 and 2018, while U5MR remained at 56 per 1000 live births during the same period, ranking as the worst in the country.

Himachal Pradesh presents an inspiring case of progress. Between 2014-15 and 2018-19, its health budget allocation increased from 5.2% to 5.9%. This commitment to public health spending led to a remarkable 48% reduction in NMR (from 25 per 1000 live births in 2014 to 13 per 1000 live births in 2018) and a 36.1% reduction in U5MR.

The compelling stories of Kerala and Himachal Pradesh, alongside the struggles encountered by Madhya Pradesh, reveal the profound impact of sustained investments in public health, offering invaluable insights for other states seeking progress in this critical area. These accomplishments embody the essence of the Directive Principles of State Policy, which emphasize the government's duty to provide healthcare access and enhance public health, as envisioned by Dr. Ambedkar. By embracing this guiding principle, Indian states can strive to realize the aspirations of the Constitution and uplift the health and well-being of their people, creating a brighter future for all.

The need of the hour today is to respond to the electorate's call and uphold the aspirations laid out in the Constitution. It is essential that public health investment, strategic policy interventions, and unwavering government commitment to healthcare provision be prioritized.

The road ahead calls for enhanced communication and understanding of the distinct roles of various levels of government, reinforcing accountability, and fostering cooperation within the health sector. By acknowledging the challenges and opportunities that lie before us, India, as a nation, can navigate the intricate landscape of public health and work towards building a healthier, more equitable future for all its citizens.

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Edited by Parth Sharma.

Image by Deekshith Vodela.