Ayushman Bharat, the new, flagship health initiative of the government, has two dimensions:
1. Comprehensive primary health care
1. Comprehensive primary health care
Currently limited primary healthcare so far:
- So far, the country’s primary health care has been focussing on reproductive, maternal health, newborn and child health as well as controlling priority communicable diseases.
- All this perhaps covers only 15% of our needs.
- Public health action for preventive/promotive health has also been limited.
Many health care needs unmet:
- There is a huge unmet need for primary health care, including:
- Care for non-communicable diseases (specifically, prevention and early detection and treatment of hypertension, diabetes, chronic obstructive lung disease, and common cancers)
- Mental health
- Care of the aged
- Adolescent health
- Palliative health care
- Basic eye care and
- Dental health
Ayushman Bharat aims to provide comprehensive health care:
- Ayushman Bharat aims to roll out comprehensive primary health care with Health and Wellness Centres (HWCs).
- The Budget speech called HWCs the foundation of India’s health system.
- HWCs would upgrade and increase the capacity of these centres to provide care for a large range of chronic illness and infectious disease.
- A nationwide network of 1.5 lakh HWCs will be created by transforming the existing sub-centres and primary health-care centres (PHCs) by 2022.
- The HWCs are somewhat on the lines of the U.K. general practices health system, but run largely by nurse practitioners and trained health workers, which are accessible near home.
- This will constitute the very foundation of New India’s health care system.
- The government has committed for two-thirds of resources to go into a comprehensive primary health care as part of the National Health Policy 2017.
Will lead to healthier India:
- If we build a strong, robust next generation primary health-care system, it will save lives and will lead to a healthier India.
- For instance, detecting and treating diabetes from the age of 35 years by a screening test would avert kidney failure at 50 years in case the condition remains undetected and untreated.
- Prevention and positive behaviours are the key to good health, productivity and a long life.
- Healthy families, villages and cities is the goal of the primary health-care system.
- HWCs will help unleash a people’s movement for a healthy India.
- The second dimension of Ayushman Bharat is the National Health Protection Scheme (NHPS).
- NHPS aims to provide health cover of Rs. 5 lakh per family per year for hospitalisation in secondary and tertiary care facilities.
- The target beneficiaries of the proposed scheme will be more than 10 crore families (50 crore people, or about 40 per cent of the population) belonging to poor and vulnerable population based on SECC database.
- In one go, 40% of people, neonates to young and old, will have access to facility care for almost all the medical and surgical conditions that could occur in a lifetime.
In cooperation with states:
- The programme would align with what the State governments are doing already, with significant resources coming from the Centre.
- Many State governments could extend the benefits to additional beneficiaries through their own resources. If that happens, the population ultimately covered for catastrophic expenses could be two-thirds of India’s population, if not more.
- This mission enables increased access to in-patient health care for the poor and lower middle class.
- The access to health care is cashless and nationally portable.
- Treatment will be provided by empanelled public and private hospitals.
Guidelines for care in private hospitals:
- Private hospitals will have to agree to terms such as package rates, adherence to standards and guidelines, ethical practice, respectful care and client satisfaction, and transparency.
Lessons from RSBY not incorporated:
- This scheme seeks to build on existing Rashtriya Swasthya Bima Yojana (RSBY), but does not address many problems associated with RSBY.
- Reviews show that RSBY has not reduced health-care costs for the poor, with many States discontinuing it.
- There is no evidence that the NHPS will correct the distortions associated with RSBY, so results may be similar.
- The initial allocation of Rs. 2,000 crore to cover 50 crore households may fall short of funds necessary.
- Even the later projected amount of Rs. 11,000 crore is, by some estimates, less than half of the amount required for this scheme.
- The other component of Ayushman Bharat is 1.5 lakh Health and Wellness Centres projected to provide comprehensive health care.
- With Rs. 1,200 crore supposed to be committed in the Budget for this, this would support only about 10,000 HWCs — less than 7% of what has been projected.
- The current year’s health Budget shows no dedicated allocation for HWCs, rather this will have to be carved out of the existing NHM budget, which has itself seen a 5% cut compared to revised Budget estimates of last year.
Overlaps with States’ insurance schemes:
- Many large States already have established health insurance schemes, and for most requirements their existing allocations were quite adequate.
- The NHPS is not a move towards Universal Health Care since
- Even in the best case scenario, 80 crore (60% of the population) would be left out.
- Outpatient care (where treatment is done at a hospital/clinic but patient does not stay overnight), which caters to the majority of health-care needs and accounts for 70% of people’s expenditure, is not covered.
- Being focussed on hospitalisation, there is no evidence that it would be integrated with primary level health care.
Insurance not same as Healthcare:
- Equating of health care with insurance schemes is problematic.
- Example of US: The U.S. is the only developed country without a Universal Health Care (UHC) system; based on commercial health insurance, its system is very expensive and excludes a huge number of people.
- Introducing the American model based on commercial insurance could be unsustainable for India, and may lead to unnecessary procedures without improvement in health outcomes.
Essential pre-requisites for success of HWCs:
1. Additional allocation:
- The first is an additional budgetary allocation of about Rs. 20 lakh per HWC per year, which would work out to about Rs. 30,000 crore per year.
- But there are no indications of such a commitment — either in this year’s Budget nor the budget allocation that went along with the extension of the NHM.
2. Greater number of regular work force:
- It needs a matching human resource policy — which includes in the least a regular salaried workforce of at least three auxiliary health workers per HWC.
- Also, measures need to be taken so that these 3 lakh health additional workers would be recruited, trained and retained, so that they are available where they are needed most.
- But on the ground, governments, driven by both ideological and financial barriers, have been reducing recruitment and contractualising the work force.
3. Referral mechanism:
- This also needs a well-coordinated referral mechanism with specialists and doctors in the secondary and tertiary hospitals.
- But there is very limited effort, investment and even thought going into this.
For effectiveness of insurance:
1. Investment needed for health facilities:
- Insurance does little for access to hospital care in vast areas where there are no providers.
- That needs public investment.
2. Need for effective regulation:
- Given the high levels of information asymmetry, the consumption of services is determined more by what private providers find more profitable to provide, rather than health-care needs of the poor.
- Thus this sector needs effective regulation of the private sector.
NHPS could play alternative roles:
Supplementing care at public hospitals:
- The NHPS could play a useful role, as an alternative and more flexible financing route for tertiary care in both public hospitals and for purchasing care from a more public service and less commercially oriented segment of the private sector where there are critical gaps.
- It could have been designed to supplement rather than substitute the public hospital.
- Some States have shown this is possible.
Supporting States’ insurance programmes:
- Where States have already established insurance programmes, the NHPS could finance these, instead of replacing them.
GS Paper III: Social Issues