New Delhi: Year 2021, the second year of the COVID-19 pandemic, started with the Central government putting emphasis on the public health sector by announcing a 137 per cent increase in the health budget. This, according to experts, was a step in a positive direction as ‘Health’ has been one of the consistently underfunded sectors. But what has been the impact of the increased allocation so far on the public health services as the country continues to fight the pandemic? Here is a look back public health sector in 2021:
Union Budget For Health And Wellbeing – A Recap
On February 1, Union Finance Minister Nirmala Sitharaman announced an increase in the allocation for health by 137 per cent to Rs. 2.23 lakh crore (Rs. 2,23,846 crore) from the previous year’s budget estimate of over Rs. 94,000 crore (Rs. 94,452 crore) and by 118 per cent from the previous year’s revised budget of over Rs. 1.02 lakh crore (Rs. 1,02,873 crore).
It is important to note, however, that the outlay included budgets for the Prime Minister’s Overarching Scheme for Holistic Nourishment (POSHAN), the Department of Drinking Water and Sanitation, and Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) apart from the allocation made for the Ministry of Health and Family Welfare (MoHFW) which is the nodal ministry for healthcare in the country.
If one deep dives into the numbers, one finds that the budget allocated for health (which includes MoHFW and MoAYUSH) saw only an 11.42 per cent increase. Therefore, despite the claim of the 137 per cent increase in health and wellbeing budget, the actual increase in health budget is much less and according to the Union Budget 2022-21, the public health expenditure in the country is just 1.2 per cent of the GDP (Gross Domestic Product) which has remained just a little over one per cent since many years. The National Health Policy 2017 recommends the health expenditure to be at least 2.5 per cent of the GDP.
The budget for Nutrition, which is vital to the health of the people, saw a reduction. POSHAN Abhiyaan was restructured from Financial Year 2021-22 onwards and combined with three schemes under the Umbrella ICDS (Integrated Child Development Services) to form Saksham Anganwadi and POSHAN 2.0. For the new composite scheme, the government has allocated a budget of Rs. 20,105 crore, almost 18 per cent less than the total BE 2020-21 of Rs. 24,557 core. Out of the allocation for Saksham Anganwadi and POSHAN 2.0, Rs. 2,700 crore for the POSHAN component of the integrated scheme was taken in account as part of the Health and Well Being budget.
Healthcare With Respect To COVID-19 During the Year
According to Dr Aviral Roy, Consultant, Critical Care, Medica Superspeciality Hospital, Kolkata, COVID-19 pandemic has paved a way for transforming the healthcare sector in the country. Dr Roy said that the year 2021 tested the resilience of India’s healthcare infrastructure, which revealed gaps in its system. During the devastating second wave of Covid, which is said to be caused by the Delta variant, there were numerous reports exhibiting a total collapse of the public health sector in the country. In April-May 2021, India witnessed an unprecedented number of hospitalisations, people were gasping for oxygen, finding it difficult to access necessary healthcare. The prices of medicines sky-rocketed and people were left to arrange for oxygen by themselves.
However, in a response (Dated December 17, 2021) to a question raised in Lok Sabha MoHFW said that all states and UTs have revamped the health infrastructure including beds, ventilators, Oxygen support among others. According to the MoHFW, following steps have been taken for augmenting the infrastructure and preparing for the future the anticipated third wave as the number of Omicron cases increase in the country:
- ‘India COVID-19 Emergency Response & Health System Preparedness Package II’ has been approved by the Cabinet with Rs. 23,123 crores (with Rs. 15,000 Cr as Central Component and Rs. 8,123 Cr as State component) and has been implemented from July 1, 2021.
- Under the aforementioned package, support will be provided to states/ UTs for strengthening health infrastructure including those in rural, tribal and peri-urban areas.
- MoHFW will also support the states and UTs in the procurement of drugs and diagnostics to enhance service delivery at district and sub-district levels for management of COVID-19 cases (including paediatric care) and for maintaining a buffer of drugs, support for IT Interventions and expanding access to teleconsultations in all districts.
- It is also providing support for capacity building and training for all aspects of the management of COVID-19.
- Testing, genomic sequencing and surveillance has been increased over the past few months. According to MoHFW, as on December 14, 2021, more than 3,000 operational laboratories are conducting Covid tests and reporting to the Indian Council of Medical Research (ICMR).
‘World’s Largest Vaccination Drive’
The year started with the government of India launching the nationwide immunisation drive against COVID-19. The vaccines being used in the drive are Serum Institute of India’s Covishield, Bharat Biotech’s Covaxin and Russia’s Sputnik V. According to the Central government, it is the world’s largest vaccination drive.
The rollout of the Covid Vaccination Drive in India:
- January 16: Launch of the Phase 1 of the nationwide Covid vaccination drive. Healthcare and frontline workers were inoculated in this phase.
- March 1: The next phase of vaccination launched for people aged above 60 and those aged 45 and above with specified co-morbid conditions.
- April 1: Vaccination for all people aged above 45 started.
- May 1: Vaccination drive was further expanded by allowing everyone above the age of 18 to get vaccinated.
- November 3: MoHFW launched ‘Har Ghar Dastak’ campaign with an aim to raise awareness and increase the pace of vaccination of the eligible population by providing immunisation service at home. According to MoHFW, the campaign has resulted in a spike of 5.9 per cent in the first dose coverage, and a jump of 11.7 per cent in the second dose coverage.
- December 25: The Centre approved vaccination for the population in the age group 15-18 who can start registering from January 1 and will be getting vaccinated using Bharat Biotech’s Covaxin from January 3. The government has also approved ‘precaution doses’ (to be taken after nine months of the second dose) for the healthcare and frontline workers and those above 60 years of age with comorbidities. The eligible population will start getting the third dose of the Covid vaccine from January 10.
According to CoWIN (Covid Vaccine Intelligence Network) dashboard, more vaccines are being administered per day in the rural areas than the urban areas with help of the ASHAs (Accredited Social Health Activist), makeshift vaccine clinics and PHCs (Primary Healthcare Centres). However, according to experts, during the earlier stages of the drive, immunisation in the rural areas was slow due to logistical problems like vaccine supply, transportation, storage bottlenecks along with vaccine hesitancy.
After 11 months of the drive, the country has been able to fully inoculate about 43 per cent of its total population and over 60 per cent of the population has received at least one dose of Covid vaccines. Experts say that while vaccination is voluntary but everyone should get it as even before the Covid outbreak, the mass vaccination programmes of the government has helped build immunity among people and eradicateD diseases like Polio and Small Pox.
Public Healthcare Infrastructure Improved But Still A Long Way To Go
According to the April-June 2021 report of the Health Management Information System (HMIS) of the Ministry of Health and Family Welfare (MoHFW), that ranks states based on indicators covering Reproductive and Child services, In-Patients and Out-Patients services and Bed Occupancy, these states have performed better than other states in terms of infrastructure and services:
- Tamil Nadu
- Andhra Pradesh
- Himachal Pradesh
- Lakshadweep; and
The states and UTs that performed worst are:
- Uttar Pradesh,
- Arunachal Pradesh,
- The Dadra and Nagar Haveli
- Daman and Diu
For improving the infrastructure and services in the poor performing states/UTs, the MoHFW said that not only should states/UTs need to improve their indicator specific programme performances to improve their overall score, but they also need to compete with each other.
In October 2021, the Central government launched PM Ayushman Bharat Health Infrastructure Mission (PMABHIM) which was first proposed in the Budget 2021-22 with an outlay of Rs. 64,180 crore over five years. The total outlay for the current year 2021-22 is Rs 9,155.97 crore. The scheme will be focused on:
- Developing primary, secondary, and tertiary healthcare systems;
- Strengthening existing national institutions;
- Creating new institutions for the detection and cure of new diseases.
According to MoHFW, so far, under this scheme, the setting up of integrated public health laboratories in all districts has been provisioned and the government is developing critical care hospital blocks in 602 districts.
The MoHFW has said that 157 new medical colleges have been sanctioned under the Centrally Sponsored Scheme for ‘Establishment of New Medical Colleges Attached with Existing District/Referral Hospitals’. Out of these, 70 medical colleges have become functional.
According to MoHFW, under Ayushman Bharat, the existing Sub-health Centres (SHCs) and Primary Health Centres (PHCs) are being transformed into Ayushman Bharat Health and Wellness Centres (AB-HWCs) to deliver comprehensive primary health care that includes preventive, promotive, curative, palliative and rehabilitative services which are universal, free and close to the community. As per MoHFW, as of now, a total of 80,545 Ayushman Bharat Health and Wellness Centres (AB-HWCs) are operational.
Dr Lingaiah Amidayala, Medical Director, Yashoda Hospitals, Hyderabad said that in terms of the workforce, there is still a need to increase nurses, doctors, other medical staff. However, he highlighted that this year, the government has increased the number of seats in many medical and nursing colleges which will help in strengthening the medical workforce in future.
Maternal And Child Care and Immunisation
According to the April-June 2021 report of the HMIS of MoHFW, Tamil Nadu, Andhra Pradesh, Karnataka, Maharashtra, Chandigarh, Puducherry and Dardar & Nagar Haveli performed better than other states in registering more pregnant women for institutional care and delivery and providing better care to them.
The National Family Health Survey- 5 (2019-21) also highlighted that institutional births have increased substantially from 79 per cent to 89 per cent at an all-India level. At the same time, the national average for out-of-pocket expenditure per delivery in a public health facility reduced by 8.8 per cent, from Rs. 3,197 in 2015-16 to Rs. 2,916 in 2019-21. The reduction in the out-of-pocket expenditure indicates that the expenditure done by the people seeking medical from their own pockets has decreased and the expenditure done by the government for the public health service has increased.
NFHS-5 data for 22 states and UTs, that were collected between June 1, 2019 and January 30, 2020, were released in December 2020. The second phase of the survey was conducted in the remaining states/UTs between January 2, 2020 and April 30, 2021, and its data was released on November 24, 2021.
NFHS 2019-21 also shows that other indicators for maternal healthcare have also seen improvement. For example, the percentage of mothers who consumed iron and folic acid for 100 days or more when they were pregnant has increased from 30.3 per cent to 44.1 per cent across India. Exclusive breastfeeding to children under six months of age has shown an improvement at an all-India level from 55 per cent in 2015-16 to 64 per cent in 2019-21.
The Health Management Information System report for April-June 2021 also shows that Andhra Pradesh, Jammu & Kashmir, Maharashtra, Telangana, West Bengal and Ladakh are performing better in terms of increasing the number of fully immunised children while Manipur, Nagaland and Dadar & Nagar Haveli are the worst performing. According to the recent NFHS numbers, India has made good progress in child immunisation indicators: 76.4 per cent of those in the 12-23 months age group were reportedly vaccinated with BCG (Bacillus Calmette–Guérin) / measles and three doses each of polio and DPT (diptheria, tetanus toxoids and pertussis) vaccine in 2020, up from 62 per cent in 2015, a growth of 23.23 per cent.
Tackling Malnutrition And Anaemia Remains A Big Challenge
According to NFHS-5, anaemia among women has increased across most states, despite the Centre’s Anemia Mukt Bharat programme which comes under the Prime Minister’s Overarching Scheme for Holistic Nourishment (POSHAN) Abhiyaan and its target of reducing anaemia by 3 per cent per year. In 25 of 36 states and UTs, over half the women in the age group of 15-49 were anaemic.
The status of child anaemia is even worse. NFHS-5 data shows that over 67 per cent of children below five years in India are anaemic. That translates to about seven in every 10 children suffering from iron deficiency.
Further, the NFHS-5 shows stunting, wasting and under-weight parameters have shown improvement over the last survey.
- Stunting (low height-for-age) among the kids under the age of 5, declined from 38 per cent (NFHS-4) to 36 per cent.
- Wasting (low weight-for-height) among the kids under the age of 5, has come down from 21 per cent (NFHS – 4) to 19 per cent.
- When it comes to underweight children, there has been a decline from 36 per cent (NFHS-4) to 32 per cent in NFHS-5.
- However, Children under the age of 5, who are overweight has increased from 2.1 per cent (NFHS-4) to 3.4 per cent.
Increased Role Of Sanitation And Hygiene
According to experts, since the COVID-19 breakout, hygiene and sanitation has assumed an even more important role. Here is why handwashing is so important:
- Frequent handwashing with soap and water is one of the best ways to prevent the spread of infectious diseases, and considered as the first line of defence against COVID-19.
- Even in the pre-COVID times, handwashing was considered as a cost-effective public health intervention for reducing burden diseases like Diarrhoea, malnutrition, worm infestation, Cholera and Hepatitis A.
A report of WHO-UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene on WASH in schools highlighted that schools with sanitation facilities not only help retain students but also lead to positive health outcomes for them. Estimating that millions of school children are being benefited by WASH programmes in India, the WaterAid school WASH Research: India Country Report states that “Handwashing with soap is making a remarkable breakthrough as a part of WASH Programmes, which is now being mainstreamed as a requirement of the nationwide midday meal scheme, which benefits nearly 110 million children in 1.3 million primary and upper primary schools.” According to experts, in the times of COVID-19, the future of education depends on the provision of water, sanitation, and hygiene services.
The Swachh Bharat Mission and the Jal Jeevan Mission are among the key initiatives taken by the government of India towards providing access to clean water and safe sanitation to the people. The WHO estimated that the Swachh Bharat Mission played an important role in averting close to 3 lakh deaths due to diarrhoea and malnutrition between 2014 and 2019. According to the Ministry of Jal Shakti, the government is aimed at providing piped water to all the rural houses by 2024. As on December 22, 2021 over 8.68 crore of the total 19.22 crore rural households have been provided with piped water connections.
On October 1, Prime Minister Narendra Modi launched Swachh Bharat Mission-Urban 2.0 and Atal Mission for Rejuvenation and Urban Transformation (AMRUT) 2.0 with an aim to make cities garbage-free and water-secure. SBM-U 2.0 is focused on achieving 100 per cent waste processing along with remediation of legacy dumpsites, construction and demolition waste and plastic waste management. For ranking the cities under SBM-U 2.0 be 50 per cent of the weightage has been allotted to Door-to-Door Collection, Source Segregation, Waste processing and Dumpsite remediation.
NDTV – Dettol have been working towards a clean and healthy India since 2014 via the Banega Swachh India initiative, which is helmed by Campaign Ambassador Amitabh Bachchan. The campaign aims to highlight the inter-dependency of humans and the environment, and of humans on one another with the focus on One Health, One Planet, One Future – Leaving No One Behind. It stresses on the need to take care of, and consider, everyone’s health in India – especially vulnerable communities – the LGBTQ population, indigenous people, India’s different tribes, ethnic and linguistic minorities, people with disabilities, migrants, geographically remote populations, gender and sexual minorities. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign will continue to raise awareness on the same along with focussing on the importance of nutrition and healthcare for women and children, fight malnutrition, mental wellbeing, self care, science and health, adolescent health & gender awareness. Along with the health of people, the campaign has realised the need to also take care of the health of the eco-system. Our environment is fragile due to human activity, which is not only over-exploiting available resources, but also generating immense pollution as a result of using and extracting those resources. The imbalance has also led to immense biodiversity loss that has caused one of the biggest threats to human survival – climate change. It has now been described as a “code red for humanity.” The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene. Banega Swasth India will also be taking forward the dream of Swasth Bharat, the campaign feels that only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and the country can become a Swasth or healthy India.