India is presently in a state of health transition. Infectious diseases such as tuberculosis, malaria, dengue, H1N1 pandemic influenza and antimicrobial resistance remain a continued threat to health and economic security. At the same time, the country is having to confront the emerging problem of chronic non-communicable diseases such as cardiovascular diseases, diabetes, cancer which are now the leading cause of mortality.
This epidemiological transition is being fueled by social and economic determinants of health, as well as by demographic changes such as an ageing population, by environmental factors such as climate change, and by factors such as globalization, urbanization and changing lifestyles.
As a result, the health infrastructure is already under severe strain. Moreover, the high cost of health care and out of pocket expenditure force families to sell their assets, pushing nearly 60 million people every year into poverty.
The New Initiative
To address these challenges, Finance Minister Arun Jaitley on February 1 unveiled the world’s largest government-funded health programme called National Health Protection Scheme (NHPS), covering 10 crore families or approximately 50 crore population, with Rs 5 lakh insurance cover per family per year. The scheme is for secondary and tertiary healthcare, mainly for hospital care.
This flagship scheme is likely to benefit more than 37% of the population, meaning that nearly all the poor and vulnerable families will be covered. The government will require Rs 12000 crore for it’s implementation, with cost shared on a 60:40 basis between central and state governments.
Mr Jaitley further announced setting up or converting some 150,000 subcentres in the country into so-called “health & wellness” centres which will offer a set of services including maternal and child health services, mental health services, vaccinations against selected communicable diseases, and screening for hypertension, diabetes, and some cancers. The sub-centres which at present cater to a population of about 5000 people each and are manned by two paramedical staff.
The Ayushman Bharat programme is apparently driven by two main aims: 1) to strengthen primary health care which has been lacking in the country and 2) to offer finacial protection from catastrophic expenditure, often encountered once a family member is sick and needs long-term health care.
Implementation is Key
The scheme, if implemented properly could be a game changer by enhancing access to health care including early detection and treatment services by a large section of society who otherwise could not afford them. The identification of beneficiaries can be done by linking with Aadhar and similarly following up for services received and health outcomes achieved, thereby helping to monitor and evaluate the impact of the programme.
Ultimately, NHPS could help country move towards universal health coverage and equitable access to healthcare which is one of the UN Sustainable Development Goals or SDGs.
This new scheme builds on the already existing Rashtriya Swasthya Bima Yojna or RSBY – a health insurance scheme for the below poverty line families, with entitlement of upto Rs 30,000 per annum for diseases requiring hospitalization. However, given that states are expected to agree for 40 per cent share under the NHPS and that health being a state subject, state ownership and commitment will be critical for the success of the programme.
The Finance Minister has made a budget allocation at Rs 52,800 crores for the health ministry, up from Rs 47,352 crore during the previous year signifying an increase of 11%, yet as percentage of the GDP, it is still among the lowest in the world. In addition, government plans increase the levy of health cess from 3 to 4%. According to health minister J P Nadda, Rs 2000 crore has been allocated as of now.
It is clear that the NHPS scheme, which primarily offers support for clinical services such as hospitalization, is unlikely to help fix the broken public health system in the country. The most critical issue remains the limited and uneven distribution of human resources at various levels of health services, with up to 40 per cent of health worker posts lying vacant in some states. Most primary health care centres suffer from perennial shortage of doctors and even district hospitals are without specialists.
Without addressing the human resouce situation, public sector health care will remain of poor quality and largely unacceptable, forcing patients to go to the private sector. Therefore, it seems as if NHPS is likely to benefit private parties more than government health services. This will ultimately be unsustainable and even detrimental for the poor for whom the scheme is intended.
To maximise benefits, it may be wise to establish a link among various health initiatives announced in the budget and also with related programmes such as the National Health Mission.
Clarity is also needed on what services will be provided by government health facilities and for which conditions patients will have to use private parties and what mechanisms are being thought of. There is a need for uniformly pricing systems for various health interventions, including diagnostics and medicines, and making them transparent by displaying them in hospital premises.
Moreover, a continuum of care system also needs to be established by linking institutions or hospitals, with health centres and the community. Community engagement is thus crucial in planning and implementation of the programme and in ensuring that the health and wellness centres and the primary health centres are responsive to the needs of the community.
For the success of the programme, effective implementation is the key. For this an independent body or unit may be set up within the ministry of health & family welfare to plan, coordinate, and provide technical backstopping to states, including in capacity building and development of standards and guidelines for the programme. Such a unit will ensure uniform and systematic approach to programme implementation across the country.
Finally, the scheme is innovative and path-breaking in the history of public health in India, which may have a transformative impact if implemented in an effective and coordinated manner. The enduring interest and level of discussion in the media does reflect the wider realization in the country that only healthy people can build a strong and prosperous nation.