Budget: Time to put primary healthcare at the heart of India’s health system

The most urgent expectation from this Budget is a clear and credible commitment to increasing the public investment in health. India is still significantly far from the long-stated target of allocating 2.5% of GDP to health, and this Budget must substantially bridge that gap.

How we spend this money also matters. We have been witnessing a concerning trend where the proportion of public health expenditure going towards primary healthcare has declined, while spending on tertiary care has increased. This must be reversed. Strong primary healthcare is the foundation of an efficient and equitable health system. By diagnosing and managing health issues early, we can significantly reduce the burden on tertiary hospitals and lower overall health and out-of-pocket expenditure. But our current model remains heavily skewed towards hospital-based treatment, and we have barely even scratched the surface of preventive care, palliative care, rehabilitation, geriatric care and long-term care for people with disabilities.

Budgetary allocations must also go beyond physical infrastructure to focus on human resources. We not only need more doctors, and specialists, in our rural areas, but also in-service training and mentoring of the entire primary health care team, including nurses, auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs), community health officers (CHOs), and male health workers. The national network of well-staffed and stocked health and wellness centres (Ayushman Arogya Mandirs) has made it possible to deliver comprehensive primary healthcare and focus on improving population health.

What's needed is a team that feels responsible for the health of the population it serves—30,000 people per primary health centre—and is held accountable.

India has made progress in building a digital health ecosystem, including ABHA numbers under the Ayushman Bharat Digital Mission, facility and physician registries. There are multiple sources of health data—but they all sit in silos. Frontline health workers fill dozens of physical registers in addition to a growing number of apps on their mobile phones. These systems now need to be integrated in meaningful ways. Health data should not merely be collected, but actively used for data-driven decision making. For instance, at the district level, health dashboards should enable collectors and health officials to identify local disease burdens, leading causes of death and plan resource allocations based on local priorities.

Another key expectation from this Budget is a stronger emphasis on climate resilience in health planning. India is already witnessing more frequent heatwaves, floods and extreme weather events, and these trends will only intensify. The health system must be prepared to respond without being pushed to the brink, as we witnessed during the Covid-19 pandemic when health workers reached severe exhaustion and burnout. The Budget must provide physical infrastructure upgrades and manpower in climate disaster-prone areas to ensure that the system doesn’t break under pressure of future crises.

For India to retain her status as the ‘pharmacy of the world’, a science-based, independent and agile regulatory framework is the need of the hour. Weak regulatory systems undermine public trust and damage India’s global reputation as a reliable producer of medicines and vaccines. Whether in drug regulation or food safety, agencies such as the Central Drugs Standard Control Organisation and Food Safety and Standards Authority of India must be strengthened by bringing in more scientific expertise and granting them greater autonomy. Regulators must be technically-qualified, of high calibre, and empowered to act independently and decisively. The prolonged delay in implementing front-of-pack labelling due to industry pressure highlights the urgent need for stronger and more independent regulators in the country.

Finally, while government funding for health research (DHR, ICMR) has shown an increasing trend, states must invest in departments of health research. This will help health systems to become “Learning Health systems", where all major policies and programs are regularly evaluated and improved. Capacity for research in medical colleges also needs to increase so that they can work with local policy makers to address local and contextual issues. We also need the private sector to step up. India has one of the lowest levels of private sector Research & Development (R&D) investment globally. Large, profitable companies must begin ploughing funds back into R&D to drive home grown innovation.

Dr Soumya Swaminathan, chairperson of M.S. Swaminathan Research Foundation.