Friday, April 13, 2018

Can Ayushman Bharat make for a healthier India? APRIL 13, 2018 00:02 IS

Building a robust primary health-care system will save lives and lead to a healthier India

Ayushman Bharat, the new, flagship health initiative of the government, has two dimensions. First, it aims to roll out comprehensive primary health care with Health and Wellness Centres (HWCs) serving as the people-centric nuclei. A nationwide network of 1.5 lakh HWCs will be created by transforming the existing sub-centres and primary health-care centres by 2022. This will constitute the very foundation of New India’s health care system.
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. There is a huge unmet need for primary health care, namely, 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.
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.
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. 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.
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.

Providing insurance

The second dimension of Ayushman Bharat is the National Health Protection Scheme which aims to provide health cover of ₹5 lakh per family per year for hospitalisation in secondary and tertiary care facilities. In one go, given the ambitious size of the package, 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. The programme will cover half a billion people and would align with what the State governments are doing already, with significant resources coming from the Centre. Many State governments would extend the benefits to additional beneficiaries through their own resources so that ultimately the population 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. The scheme would enable a weaver in a remote village to be able to walk into a hospital for a gall bladder stone surgery or a coronary stent without having to pay the hospital. Treatment will be provided by empanelled public and 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.
Ayushman Bharat will spur increased investment in health and generate lakhs of jobs, especially for women, and will be a driver of development and growth. It is a turning point for the health sector.
Vinod Paul is Niti Aayog member and a professor of paediatrics at the All India Institute of Medical Sciences.
(As told to Anuradha Raman)

With no preventive, promotive or outpatient care, it may not lead to larger public benefits

No. In brief, because its centrepiece, the National Health Protection Scheme (NHPS), also called ‘Modicare’, is just an existing scheme re-announced with some expansion; the funds allocated are grossly inadequate; this scheme would overlap with many established State health insurance schemes; and most importantly, the scheme does not deal with preventive, promotive or outpatient care, so it is unlikely to lead to larger public health benefits.

Old wine in a new bottle

The NHPS is not a new scheme, in fact it was announced in the 2016 Budget — the only difference being that the sum assured until now was ₹1 lakh, which has been raised to ₹5 lakh. In the last two years, the NHPS has been a non-starter — the reason for its failure is that many large States already have established health insurance schemes, and for most requirements their existing allocations of ₹1.5-2 lakh were quite adequate. So, this ‘old wine in new bottle’ scheme offers hardly any advantage.
The allocation of ₹2,000 crore to cover 50 crore households, amounting to barely ₹40 per person per year, is barely enough to cover one strip of tablets annually. Even the later projected amount of ₹11,000 crore is less than half of the minimum amount required for this scheme.
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 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 (responsible for 70% of people’s expenditure) is not covered; and being focussed on hospitalisation, there is no evidence that it would be integrated with primary level health care.
The Finance Minister made a hilarious statement that the NHPS is the ‘world’s largest government-funded health care programme’, shocking since the scheme is allocated just ₹2,000 crore, while the government’s own National Health Mission with annual outlay of ₹30,000 crore is ignored. India’s public health services are allocated close to ₹100,000 crore annually.
However, such equating of health care with insurance schemes is extremely problematic. 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 is unsustainable for India, and may lead to unnecessary procedures without improvement in health outcomes. There are strong reasons to believe that the main intention of the NHPS, launched by a ‘business friendly’ government, may be to include and support corporate health-care providers, while boosting health insurance companies.
The other component of Ayushman Bharat is 1.5 lakh Health and Wellness Centres projected to provide comprehensive health care. With ₹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. More seriously, scrutiny of 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.
Given all this, ‘Ayushman Bharat’ with its promise to cover ₹5 lakh for every family, should not become another ‘jumla’.
Abhay Shukla is the national convenor of Jan Swasthya Abhiyan.

Public provisioning of primary care has been central to realising the right to health care

The scheme has two parts — the National Health Protection Scheme (NHPS) and the Health and Wellness Centres (HWCs). The former has received wide media coverage, the latter remains largely unknown. The Budget speech called HWCs the foundation of India’s health system. Both in the developed world and in the developing world, public provisioning of primary health care has been the central strategy of realising the right to health care. Currently, the health sub-centres and primary health centres in India are limited to only some elements of maternal and child care and control of two or three major infectious diseases. What HWCs would do is to upgrade and increase the capacity of these centres to provide care for a large range of chronic illness and infectious disease.
But there are three essential pre-requisites. The first is an additional budgetary allocation of about ₹20 lakh per HWC per year, which would work out to about ₹30,000 crore per year. This would be great value for money. 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. The second condition is a matching human resource policy — which includes in the least a regular salaried workforce of at least three auxiliary health workers per HWC. Also, reforms in the way 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. Third, this 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.

Insurance gaps

If the silence shrouding HWCs is the problem, with respect to the NHPS it is the noise. It is a publicly-funded health insurance programme, with a limited budget, designed to provide financial protection for the poor against costs of secondary and tertiary health care. Many States already have similar programmes in place. First, insurance does little for access to hospital care in vast areas where there are no providers. That needs public investment. Second, in the absence of any effective regulation of the private sector, and given 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.
Even its outcomes in terms of financial protection are uncertain. By design, such schemes exclude outpatient care which caters to the majority of health-care needs and accounts for most of the expense and impoverishment due to health-care costs. And it should stay excluded. 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. And some States have shown this is possible.
Where States have already established insurance programmes, the NHPS could finance these, instead of replacing them. And where they do not have a programme, learning from experience, if the sum assured was kept at ₹2 lakh or less, the NHPS would have a modest but important contribution to make.
But then these are times when any pro-poor public expenditure is dismissed as fiscal indiscipline, unless it can be routed in a manner where corporate private sector can profit from it.
T. Sundararaman is a professor at TISS and former executive director of National Health Systems Resource Centre.
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