The prescribed health allocation as suggested by the 15th finance commission can certainly fulfill a mandate on primary care
In the early November of 2021, a strong game-changing, and life-changing development took place, nearly unnoticed- the release of Rs 8,453.92 crore to 19 states as grants for health to both rural and urban local bodies by the Department of Expenditure, Ministry of Finance. The allotment has been made as part of a health grant of Rs 70,051 crore that will be released over 5 years from FY 2021-22 to FY 2025-26, as suggested by the 15th Finance Commission. The grant has been set aside to address known gaps in primary health care infrastructure in both rural and urban settings. Of the entire Rs 13,192 crore to be allotted in FY 2021-22, RLBs (rural local bodies) will get Rs 8,273 and ULBS will get Rs 4,919 crore respectively.
By several comparisons the allotment in FY 2021-22 is comparatively less. This would be nearly 2.3% of the entire health expenditure (comprising of both public and private expenditure) of Rs 5,66,644 crore in India and 5.7% of the yearly government health expenditure (Union and State together) of nearly Rs 2,31,104 crore (both).
This certain grant is same to 18.5% of the Union health and Family Welfare Department’s budget that is allotted for FY 2021-22 and almost 55% of the 2nd COVID-19 emergency reply package released in July 2021. Nevertheless, it is possibly the single most significant health allocation in this FY with the potential to have a greater effect on health services in the years to come in India.
Good intentions that have gone wrong
In 1992, as part of the 73rd and 74th Constitutional Amendments, responsibility for giving primary care and public health services were given to local bodies in rural and urban areas. It was thought that this would impact to bigger focus on allocation of funds for health services in the geographical jurisdiction of the local bodies. Even, rural settings continued to get funding for primary health care facilities under the national programs.
However, the decision proved to be a main setback for urban health services. Government funding for urban primary health services was not dispelled through the state health department and ULBs did not raise the allocation for health. The reasons are a lack of resources or a lack of lucidity on health-related services, or entirely different spending priorities. It was a diverse combination often of all these factors.
The inauguration of the National Rural Health Mission (NRHM) in 2005 to make the primary health care system stronger in India partially reduced the effect of health-spending RLBs. However, urban dwellers were not lucky equally. The National Urban Health Mission (NUHM) can be introduced 8 years later and with a yearly financial allocation which can be as low as Rs 1,000 crore.
After the constitutional amendments in 2017-18, ULBs and RLBs in the nation were providing between 1.3% and 1% of the yearly total health expenditure in India. In the urban areas, majority of local bodies were spending less than 1% to almost 3% of their yearly budget on health, which is nearly less than what urban local bodies spend on installation and repair of the lights in the streets. The result has not been entirely shocking. Both urban and rural India need much more health services. Though, the challenge in rural areas is bad functioning of available primary health care facilities which in urban parts it is a lack of primary health infrastructure and services both.
Urban part of India, with nearly only half the rural population, has one-sixth of the primary health centres when compared to rural parts. Contrary to what we might think, services available in rural India are better than the services in urban primary health care. Frequent outbreaks of dengue and chikungunya and 2 waves of the Covid-19 pandemic have resulted in people having issues for counselling and testing services related to Covid-19. The low importance given to health and less funding is compounded by a lack of unity among the multitude of agencies that are responsible for various types of health services. Few years back, there were few reports of Delhi refusing to give land for the construction of 3 municipal corporations. Clinics in the streets and even several under construction clinics were vandalised.
It is against this framework that the Fifteenth Finance Commission health grant: the urban part is almost about 5 times the yearly budget of NUHM, and the rural part is one and a half times the entire expenditure by the Rural Local Bodies. In India, there is an unparalleled opportunity to fulfil the instruction given under 2 constitutional amendments in 1992. However, for it to work well, several coordinated steps are needed.
Steps that are needed
To make use of the grant firstly as an opportunity to sharpen stakeholders in local bodies which includes elected representatives (councillors and representatives of Panchayati Raj Institutions) and administrators, about the role and works in the delivery of primary care and public services related to healthcare. Secondly, the awareness among the citizens about the responsibilities of local bodies should be highly increased in health care services. This approach can help as a powerful mean to enable significance in the system. Thirdly, civil society organisations must play a vital role in increasing awareness of the role of local bodies in health and in developing local dashboards to keep a track on progress made in health sector. Fourthly, the health grants of the Fifteenth Finance Commission shouldn’t be taken as a ‘replacement’ for health expenditure by the local bodies, which should be accompanied by daily increasing their own health expenditure to make a meaningful effect. Fifth is that the mechanisms must be institutionalized for good coordination between several agencies that are operating in both rural and urban areas. Sixth is that local bodies tend to continue to be ‘health greenfield’ parts. Such young people in charge of Rural Local Bodies and Urban Local Bodies and motivated councilors and members of Panchayati Raj Institutions must take this opportunity to grow unique health models. Lastly, before the Covid-19 virus pandemic began, several state governments and cities had decided to open a variety of community clinics in both urban and rural areas. But it got paused. The money must be used to continue all these proposals.
A much-anticipated springboard
The health system of India requires more funding by the government for health. However, when its time for local bodies, it is health leadership, several agencies uniting among each other, raised citizen engagement in health, the making if accountability mechanisms and incremental financial support by elected people guiding the process. There must be a certain mix of the allocations. The health grants of the Fifteenth Finance Commission have the power to make a health ecosystem which can help to serve as the much-anticipated springboard for health that is mainstream in the working of both urban and rural local bodies. The health care system of India can’t and should not take this opportunity.