The Union Budget 2025-26, driven by a vision for developed India by 2047, has evoked mixed response across sections. In her speech, the finance minister emphasized that a developed nation is essentially its people, and acknowledged that high-quality, affordable, and comprehensive healthcare is indispensable to development. However, this idea has long been enshrined in post-independent India’s vision for development, reflected in the organization of its healthcare system.

The notable budgetary announcement in healthcare includes reducing import duty on essential medicines, including online platform workers under Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme, establishing day care cancer centers at District hospitals, and committing to broadband connectivity at the primary healthcare centers. Nevertheless, a budget that claims to reflect responsive governance seems to have missed the mark in delivering people-centered healthcare.

Not so long ago, the Covid-19 pandemic painfully taught us the significance of a people-centered primary healthcare (PHC) system. We cannot forget how our public healthcare system, despite its woes and fragmentation, valiantly battled against the pandemic to save millions of lives. Arguably, the relatively well-functioning PHC systems in the southern states of Kerala and Tamil Nadu, have made a significant difference to their handling of the pandemic. Considering the persistent threat of emerging infectious diseases and rising burden of non-communicable diseases, there was an expectation that the aftermath of the pandemic would lead to unmitigated efforts to reimagine PHC in India. But we are yet to observe any concrete steps in this regard in the budgets following the pandemic, including the most recent one.

Much has been written about basic infrastructural and human resource challenges that have plagued the PHC in India for decades. The reasons for such a state can be easily explained using the governance approach reflected in this budget. The budget prioritizes improving digital infrastructure by providing broadband connectivity to primary health centers. However, the centers struggle with basic facilities such as regular electricity, and functional equipment, including computers and tablets for digital documentation. Despite the recent international recognition of their significant work, the Accredited Social Health Activists (ASHAs), continue to work in poor conditions. This struggle is shared by other cadres of health workers in the PHC network, who, despite being overworked and underpaid, continue to serve the communities coping with infrastructural and connectivity deficiencies.

The budget’s misplaced emphasis on recruiting more doctors, including specialists, to strengthen the healthcare workforce and oversee the implementation of government programs is puzzling, since it has been repeatedly highlighted that India does not have an acute shortage of doctors, it’s patient-to-doctor ratio is almost closed to what is recommended by the World Health Organization (WHO). Instead, the problem lies in their skewed distribution. Such an expert-driven approach to public health not only leads to ineffective top-down planning but also further invisibilizes the intelligence and contributions of the grass-root level public health practitioners, such as clinical and community nurses, lab technicians, treatment supervisors, pharmacists, community health workers and volunteers. Rather, the focus should be on recruiting, training and sensitizing diverse categories of workers in primary healthcare.

A recent report by the Indian government has acknowledged the key achievements of the National Health Mission (NHM) in areas such as maternal mortality, tuberculosis, and sickle cell anemia. The report also lauded the role played by healthcare workers in the delivering services at the grassroot level. Ironically, the recent budget has reduced the allocation to NHM compared to the previous year.

The continued emphasis on secondary and tertiary care, with a bent towards private sector engagement through medical tourism and insurance, alongside the patchy focus on primary health care is strongly reminiscent of the quintessential old wine. Recent literature has explicitly highlighted that PMJAY, the much celebrated national health insurance scheme, has failed to improve utilization, quality or ensure financial protection, especially for the poorer section of the society. Reports also suggest that PMJAY appears to have become yet another tool to private sector hospitals, which often overcharge and exploit patients. Despite the lack of conclusive evidence on PMJAY’s effectiveness, successive budgets have consistently increased allocation.

The highly fragmented and struggling public healthcare system, the sole hope of the poor, is already clutching at straws to sustain itself amidst the rising demands posed by epidemiological and demographic transitions. Continuing to ignore this struggle could prove to be catastrophic to millions, even in the absence of a public health emergency like a pandemic. Since the Alma Ata declaration of 1978, there have been repeated calls for a systems approach to healthcare, with primary healthcare at its core, instead of an expert-driven, disease-centered approach. The continued focus of consecutive budgets on quick fixes, rather than on building a strong and resilient public healthcare system, indicates that five decades and a pandemic later, we have made little progress toward fulfilling this vision.

Authors: Sapna Mishra is an Assistant Professor at the Department of Sociology and Anthropology, Easwari School of Liberal Arts, SRM University, Andhra Pradesh, India.

Malu Mohan is a Public Health consultant at Chennai Dental Research Foundation, Chennai, Tamil Nadu, India.

Competing interest: None

Handling Editor: Neha Faruqui