Impact of Union Budget 2020 on Health sector

By Dr. Shyama Nagarajan

The budget 2020 reflects a shift towards including “Health in every Policy”. The focus of the allocation in the last few years has been ensuring ‘Public Good’ beyond public health infrastructure up-gradation under National Health Mission (NHM) into water, sanitation, and Ayushman Bharat. However, the constant shifting of goal post since we committed to the “Alma-Ata Declaration on Health for All by 2000 AD” is a point to ponder. This is especially relevant for India because the world watches the Indian ways of frugality in offering solutions to the underdeveloped nations. Some of the reasons that might be standing in way of achieving the desired results are:

  1. Lack of capacity within the public system to execute the proclamations made. To exemplify: while the variation in Budget Estimates to Revenue Expenditure in FY 19-20 for Integrated Child Development Scheme (ICDS) was 7.4% and that of NHM was 2% (NHM consumes 50% of the allocation of funds on Health); the latest Comptroller and Auditor General’s (CAG) report 2019, on Hospital Performance for the state of Uttar Pradesh (UP) reports only 84% of fund utilization under NHM during the period 2013-2018. Thus, what seems as 2% variation in spending at the Central level, turns out to be 16 % at the State level. Further analysis at the district level would reflect an even larger unspent amount accruing interest in the banks. This can be concluded by the same CAG’s report of UP on allocation of budget to districts on ad-hoc basis without rigorous planning and absence of regular reports to the state raising demand with details on consumption of drugs and consumables at local levels. UP is just a case state in reference, where most studies have been conducted. The situation is no different in terms of lack of capacity in many other states.
  2. Lack of trust within the envisaged Public-Private Partnerships (PPP); adhoc and short-term responses to address the shortage of skilled manpower at various levels across line ministries. One of the recent unsuccessful healthcare PPP stories is the ITKI, Jharkhand Medical City Project, which is yet to conclude for the last three years despite repeated tendering.

It is time that we deliberate and probe the reasons for these failures and find out the key stakeholders at the various levels of decision making, their expectations, to what extent expectation-provision mismatch can be tolerated by the system, and how should the institutional governance and management mechanisms be strengthened to influence adequate and appropriate utilization of funds deployed.

 Unless we as a nation internalize and find solutions, our spending will never be able to effectively impact the health outcomes in the long term.

Director’s Corner – On “CAG to tap AIIMS, IITs for report card of govt schemes”

by, Dr. Amitabh Dutta

Fantastic work. Heartiest congratulations to the CAG of India to have brought out first-of-its-kind outcome audit of performance in the district hospitals of UP. I would like to specially congratulate and thank Dr. Shyama Nagarajan of SahaManthran Pvt. Ltd. (mentioned as ‘the lady doctor from the NIPFP’ in the news report) to have actualized her innovative audit system on-the-ground to respond to and work for the CAG initiative through NIPFP. Dr. Shyama’s ‘Grading of Healthcare Services System’ (conceptualized in 2002), which helps to demystify, qualify, and quantify hyper-variable and intangible outcomes of the ever-changing healthcare sectors, e.g. from IQA (Internal Quality Audit) to draw Clinical Governance at Fortis Healthcare to the current Framework for Hospital Performance Audit of UP hospitals for CAG; would bring clarity to the entire system. I sincerely hope she would continue to support and steer (if asked) the upcoming IIT and AIIMS audit mechanisms to wade them through initial rough waters of new challenges in assessing the performance of different sectors of healthcare.’
See the news report here:

Environmental pollution and its impact on health – SahaManthran suggests solutions

By Dr. Amitabh Dutta

Forest fires in Australia are a raging & recurring issue. Repeated failures to stop bush-fires raises a question, how to prevent it the next time? Here are a few suggestions from our Director, Dr. Amitabh Dutta.

#AustraliaBurning Solution#11: The world should come together for the forest-fire problem through a global platform for real-time monitoring of forests by satellite imagery for detection & timely information; such that emergent action can be taken fast to nip the fire in the bud.

#AustraliaBurning Solution#10: At the policy level, a ‘National Anti-Forest Fire Tribunal’ should be set up with a mandate to monitor, receive feedback, induct progressive reforms, and implement changes on the ground till a full-proof system of ‘zero forest fire year’ is achieved.

#AustraliaBurning Solution#9: The forest range can be presented to the public in ways such that it stimulates public interest & participation in its protection. Within a forest, there can be: medicinal plant center, horticulture unit, agroforestry system, animal care pockets.

#AustraliaBurning Solution#8: To limit fuel emission warming up the forest, the road that runs along a forest can be designed in a double green belt pattern. The inside-out sequence to include the forest boundary, a 20 m green belt, a 4-lane road, & finally, a 20-m wide green belt.

#AustraliaBurning Solution#7: The upkeep of a range of forest can be facilitated by environment-friendly commercialization (e.g. 18-hole golf course; guided tours paths for tourists/students; rain-water harvesting) which self-sustains & tends internal health of forest ecosystem.

#AustraliaBurning Solution#6: The administration can put in place active continuous surveillance (vehicular, drones, satellite) of the forest area to lower threshold for detection of forest fire and responsive action. On the ground, manned pickets should aid monitoring.

#AustraliaBurning Solution#5: There can be many remote fire-smoke sensors places in strategic position inside the forest range & monitored centrally. Though this will probably add a minuscule to the cost, it will be much lower than managing when the forest has caught fire!

#AustraliaBurning Solution#4: As there r rules for making infrastructure around sea-fronts; rules for not allowing any construction (residential, commercial), concrete or make-shift, within 1 km range of forest should be considered. Also, no human activity around the forest be allowed

#AustraliaBurning Solution#3: Each forest has a typical, tree profile. In Indian hill forests, breaking over-clustering of trees by interspersing Pine tree (dry, exude warm air, catches fire easily) and Rhodenderon tree (wet-n-cool, fire-resistant) clusters limits spread of fire.

#AustraliaBurning Solution#2: Since fire spreads through a bed of dried leaves lying on the ground, regular clearing of leaves is the key. Also, creating walking paths from within the trees would help. Importantly, the internal tending of a forest will significantly improve protection

#AustraliaBurning Solution#1 to prevent the spread of forest fires on-the-ground: multiple artificial water-bodies (rainwater pools, ponds, puddles, wetlands) can be created inside forest range to keep the ground non-dry & the intervening tree clusters separate from each other.