In the early days of our health work at Azim Premji Foundation, I met a retired bureaucrat widely credited for key initiatives in public health across India. She patiently heard our plans for improving the public health system, and then said, “You are wasting your time. Unless there is a fundamental shift in the financing and governance of public health, all improvements will be marginal. Health has no political mileage; I don’t see this happening in my lifetime.”
To put this in perspective, in 2021-22 the government — central and states put together — spent Rs. 3,169 per capita (or 1.84% of the country’s GDP) on health. Both in terms of absolute amount per person and as a percentage of GDP, India lags almost all of its peers. Countries such as Brazil, China and Malaysia spend 3-6% of their GDP and 5-10 times per capita; in OECD nations, it is 6-10% of GDP and 100 times per capita.
The reason this is important is because health outcomes of a country are directly related to how much governments spend on health. And you see the effects of inadequate funding across the Indian health system.
It is by now common knowledge that health outcomes of a society are determined far more by investments in the frontlines of health than on anything else.
The other day, I was walking through a crowded district hospital in a well-administered western state. One of my quirks is to judge a facility by the cleanliness of its toilets. I asked the person accompanying us why the toilets were is such poor condition. He said they had just one male and one female janitor to maintain 16 toilet blocks across the 300-bed hospital, and the best they can do is to clean each of them once a day.
The guidance for developing countries is that at least 70% of public spends should be on primary health. India is at 50%.
At another government super-specialty hospital, this time in the south, its 120 beds are managed by a harried team of 60 nurses, a third of what it needs to meet Indian Public Health Standards.
The net effect of this inadequate financing is felt most at the frontlines. It is by now common knowledge that health outcomes of a society are determined far more by investments in the frontlines of health than on anything else. The guidance for developing countries is that at least 70% of public spends should be on primary health. India is at 50%.
A marginal budgetary shift is possible — where we increase public health funding from 1.9% to 2.5% of GDP, which is the guidance of the 2017 health policy.
As a result of this, the cadre of ASHAs and Anganwadi workers — who are responsible for core programs such as nutrition, vaccination, reduction in maternal and infant mortalities, screening for non-communicable diseases, and so on — do not get paid even the mandated minimum wage for unskilled workers. This is also why public insurance programs do not cover outpatient care — important because outpatient costs, especially medicines, are a significant contributor to catastrophic expenditure of poor households.
Since promotive and preventive health work is performed primarily by the frontline, this additional investment could even reduce patient load in secondary and tertiary care.
To clarify, I am not suggesting that India, given its many fiscal constraints, should spend as much on health as its peers; I understand that is asking for too much. However, a marginal budgetary shift is possible — where we increase public health funding from 1.9% to 2.5% of GDP, which is the guidance of the 2017 health policy.
If most of this increase is funneled into primary health, it could nearly double the funds available at the frontline. With this increase, we could fund a range of critical measures, for instance: improve service conditions for ASHAs and nurses and equip them better, build better last mile health facilities, extend public insurance for outpatient expenses, and so on.
Since promotive and preventive health work is performed primarily by the frontline, this additional investment could even reduce patient load in secondary and tertiary care.
If we show the political and bureaucratic will to make these small shifts, it will have far reaching effects on India’s health outcomes.