Ayushman Bharat: go beyond insurance

Often referred to as the pharmacy of the world, India produces 60% of world’s children’s vaccines and is frequently regarded as the engine of global economic, information and space technology development. Despite, being the most sought-after medical tourism destination, progress in the health indicators in India is way behind other countries which have achieved better health for their citizens.

The Lancet reported India’s position at 162 among 195 countries based on death rates of 32 diseases that are fully amenable to treatment. The country’s consistent unimpressive position on healthcare prompts us to evaluate the structure and functioning of the health system in India.

It is time to address underlying factors such as lack of investment in healthcare and a generalised approach to health, limitations of policies, and discrepancy in healthcare for rich and poor and in urban and rural areas.

Expenditure on healthcare is a major driver of poverty. An estimated 94.44 million were impoverished after incurring expenditure on medical care in 2014. About 47% of hospital admissions among rural masses and 31% among urban Indians are financed by loans and sales of assets; and 30% of the former and 20% of the latter go untreated because of financial constraints.

People-oriented

Touted as a ‘bold, ambitious and courageous move’ by Tedros A Ghebreyesus, Director-General of the World Health Organization, mission ‘Ayushman Bharat’ is an attempt to create a conducive healthcare structure, protect the interests of people and service purveyors and provide healthcare to all.

Ayushman Bharat will empower the in-need class of the country, a movement that can potentially change the face of medical service in India.

With a promise to provide Rs 5 lakh annual health cover to about 50 crore poor and vulnerable population and a plan to upgrade existing sub-centres into Health and Wellness Centres across the country, Ayushman Bharat promises to unlock the freedom of health for all. However, limitations of the mission remain.

Financing the NHPS

One of the main challenges to the National Health Protection Scheme (NHPS) is financing. Finance Minister Arun Jaitley himself stated that the scheme would require at least Rs 1 trillion annually for successful implementation. Also, inflation of care services and claim-ratios could complicate and dissatisfy users of the plan.

The government had set the goal of increasing expenditure on health to 2% by 2010 in its 2002 policy. It has reached only 1.15%, yet the goal in National Health Policy (NHP) 2017 was increased to 2.5%. Unless health receives priority attention, the new schemes launched with much fanfare such as National Health Mission (NHM) in 2004 and Ayushman Bharat, now, will not achieve the desired results.

Comprehensive review

There is a need for comprehensive review of the current health system in light of current health needs rather than adding one cadre here and one cadre there. The establishment of 1,50,000 health and wellness centres (HWC) demands inclusion of training and recruitment of healthcare providers as well as a newly-established cadre of mid-level providers to head these centres, additional staff and physical infrastructure upgradation.

The states need to be given more autonomy in expediting work on establishing HWCs plus training of new cadres. In addition to upgrading the HWCs, their population coverage norms along with Primary Health Centres and Community Health Centres must be upgraded too. Even existing infrastructure lacks staff and supplies which need to be addressed in a comprehensive manner to meet current needs.

Health in All Policies

The government also needs to give higher priority to establishing a mechanism to address health in all policies (HiAP) which has not progressed beyond fragmented multispectral action plans for tobacco control, NCDs, HIV/AIDS etc. All these need to be included under the single umbrella of HiAP. With 80% contribution to health expenditure coming from states, collaboration between the Centre and states can help design a universal model of healthcare.

Overall development of the healthcare industry and the success of Ayushman Bharat is largely dependent on the execution of the plans and addressing other problems in the system, including mainstreaming and regulation of private sector.

(The writer is Director, International Institute of Health Management Research, New Delhi)