The latest Indian budget (2015) announcement regarding the creation of six additional national-level institutes of excellence, the All India Institutes of Medical Sciences (AIIMS) has resulted in heated debate. One of the issues being raised is regarding the wisdom of investing in super-specialty institutions at a time when the overall budget for the national health sector is shrinking. The AIIMS are public medical colleges, declared by Act of Parliament as institutions of national importance. They are meant to inter alia: (a) provide for under-graduate and post-graduate medical programs; (b) provide facilities for research; (c) establish and maintain at least one comprehensive medical college and well-equipped hospital.
From 1956 until 2009, the AIIMS in Delhi, the national capital was the sole center of excellence; since 2009, the government has taken the decision to open 19 more such institutions, with the objective of eventually establishing at least one AIIMS-like institution in every state. How much does it cost? According to the financial memorandum signed in 2012 when six new institutes were introduced, an estimated cost of INR 4,920 crore ($ 8 billion) — INR 820 crore ($ 1.3 billion) per AIIMS — was approved. Compare that $ 8 billion for just six institutions with the INR 33,150 crore ($ 56 billion) allocation to the health sector in this year’s budget – only seven times as much for all the centrally-funded public health programs for the country as a whole!
Despite this hefty investment, the new AIIMS are yet to live up to their promise, with severe problems with poor infrastructure and human resource availability. This is a crucial concern, since the government’s decision to invest substantial amounts of money into tertiary level super specialty hospitals and teaching institutions has been widely criticized, especially when the primary and secondary level health care infrastructure is crumbling in most states. The need for better primary care has long been recognized in India: the Health Survey and Development Committee, headed by Sir Joseph Bhore, had recommended the strengthening of the primary care network, and the integration of preventive and curative care at all levels way back in 1943. This approach was later echoed by the Alma Ata Declaration (1978) which called for “Health for All” to be delivered through a comprehensive primary health care approach; and then adopted by the government’s flagship health program in 2005 – the National Rural Health Mission (now called the National Health Mission). The decision to strengthen tertiary care is therefore at odds with the National Health Mission’s goal of strengthening the primary and secondary levels of care for delivery of comprehensive basic health care.
Should the poor have access to high quality specialized care at an affordable cost? Certainly, without a doubt. However, at a juncture when India’s maternal mortality ratio and infant mortality rate are still unacceptably high, when there is an epidemic of malnutrition amongst women and children, when diseases such as Tuberculosis and malaria continue to claim thousands of lives, the decision to invest in individualized super-specialty care deserves careful reconsideration. The government should think of more cost-effective ways of financing the provision of specialized care for the poor, including social health insurance models, and focus on strengthening the primary and secondary care network.