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BMJ 2015;350:h1734 doi: 10.1136/bmj.h1734
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS
PERSONAL VIEW
Bureaucracy and budget revision: how spending cuts
are affecting India’s public health programmes
Healthcare in India needs more funding, not less, says Leena Menghaney, reflecting on services
for people with HIV after cuts to some health budgets of as much as 20%
Leena Menghaney lawyer working on public health law and policy, New Delhi, India
I have seen huge insufficiencies in India’s HIV programme
recently, perhaps unprecedented since I started working as an
AIDS treatment activist in 2002. It is sobering to witness people,
particularly children, getting sick because the drugs and
diagnostics that are mostly taken for granted in the developed
world are not available.
Two factors are slowing India’s progress on health indicators
and access to drugs. Firstly, the government’s health spending
has stagnated at just over 1% of gross domestic product (GDP),
when the World Health Organization recommends 5%; secondly,
the Ministry of Health and its programmes are unable to use
much of the funding that has been allocated.
Revision and reduction of allocated
spending
For example, the National AIDS Control Organisation (NACO)
was allocated a domestic budget of Rs2861 crore (£309m;
€420m; $460m)1 from 2007 to 2017, but only Rs1115 crore was
spent.2 Each financial year, when NACO fails to spend a
substantial part of its annual domestic budget, the Ministry of
Finance revises and reduces its spending. Endless bureaucratic
delays in implementing prevention and treatment services for
many of the Ministry of Health’s national programmes leaves
millions unspent—hence the routine but deadly mid-year budget
revisions.
In 2014 the AIDS programme was again presented with a
mid-year revision of its budget, and the allocation for drugs,
kits, and consumables was reduced from over Rs450 crore to
Rs157 crore.3 Unused funds were also transferred to new projects
such as Swachh Bharat Abhiyan (Clean India Mission) in the
last quarter of 2014, while frontline AIDS workers were not
paid, essential monitoring tools for HIV treatment such as viral
load kits were not purchased, and approvals of bids to procure
critical prevention tools were delayed, such as condoms and
kits for HIV testing and diagnosing sexually transmitted
infections (STIs).
Co-infections such as hepatitis C add to increased morbidity
and mortality among people with HIV. But publicly funded
treatment for co-infections in addition to antiretroviral drugs is
seen as impossible despite the availability of unspent funds.
Months without pay for healthcare
workers
This is not all. Healthcare workers employed by the National
Health Mission to provide basic medical services were not paid
for months. Funds for the national AIDS and STI control
programme and the National Health Mission were, for the first
time, sent directly to state treasuries rather than to the states’
AIDS control societies and health units.4 The policy was well
intentioned, designed to give states a greater role and more
financial power, but the central government failed to plan and
coordinate the change sufficiently. Tens of millions of rupees
are yet to be released by state finance departments, while public
health goes without.
Because funds remained unspent, it came as no surprise that the
Ministry of Finance in December 2014 revised and ultimately
announced a 15% budget cut in the health ministry’s 2014-15
expenditure. Concurrently, more than 40 million people in India
face financial hardship, debt, and impoverishment because of
out-of-pocket health expenditure (largely for drugs), while the
government continues to slash the health ministry’s budget each
year. And, for the next financial year (2015-16), the national
AIDS programme’s budget has been slashed by almost Rs300
crore from the previous year, including funding for the supply
of essential prevention tools such as condoms. The allocated
Rs1397 crore is considered barely enough for maintaining
prevention and treatment interventions at their current levels.5
The health budget for 2015-16 is only marginally higher than
the previous year’s and is nowhere near the 2.5% of GDP that
the new government’s draft National Health Policy proposes.
[email protected]
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BMJ 2015;350:h1734 doi: 10.1136/bmj.h1734
Page 2 of 2
VIEWS & REVIEWS
A disastrous go-slow policy
We should be expanding interventions for public health, such
as those for viral hepatitis and non-communicable diseases. As
50 million people with chronic hepatitis B and C struggle for
access to reliable testing, diagnostics, and treatment in India’s
expensive private healthcare sector, the government has
allocated a mere Rs5 crore for the start of a surveillance
programme by the National Institute of Communicable Diseases.
Chronic lung disease beyond tuberculosis has not been
prioritised, and early diagnosis of breast and cervical cancers
that could save the lives of millions of women is not considered
in programmes related to reproductive and sexual health.
Similarly to previous governments, this new government is
adopting a disastrous go-slow policy when it comes to increasing
the health budget and using it effectively. In India, universal
health coverage—strongly associated with poverty reduction,
economic development, and a better public health
system—remains a distant dream.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood the BMJ policy on
declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1
2
3
4
5
Working Group on Financial Management, First consultation meeting 24-26 May 2011.
http://bit.ly/1CPI4LJ.
Department of AIDS Control, Ministry of Health & Family Welfare. Annual report 2013-14.
www.naco.gov.in/upload/2014%20mslns/NACO_English%202013-14.pdf.
Department of AIDS Control, Ministry of Health & Family Welfare (Demand no 50). Union
budget 2015-16: notes on demands for grants, 2015-2016. http://indiabudget.nic.in/ub201516/eb/sbe50.pdf.
Kalra A. Payment delays dent India’s flagship health, AIDS programmes. Reuters 3 March
2015. http://news.yahoo.com/exclusive-payment-delays-dent-indias-flagship-health-aids023049886--business.html.
Prasada Rao JVR. Centre must rethink its public health policy. Hindustan Times 19 March
2015. www.hindustantimes.com/analysis/centre-must-rethink-its-public-health-policy/
article1-1327998.aspx.
Cite this as: BMJ 2015;350:h1734
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