Hyderabad: On 11th December 2019, a reputed English news daily carried an important piece of the news item, explaining how the lack of health insurance is affecting the poor in India. The report was based on the data on the key indicators of social consumption, of the NSS 75th round (2017-18), released recently. It highlighted the issue of poor households resorting to borrowing or spending from their hard-earned savings, to meet their expenses on health, due to lack of health insurance coverage and also brought forward the skewed distribution of patterns in the urban and rural divide over the health expenditure.
Incidentally, just a day before this coverage, i.e., on 10th December 2019, the Union Minister of State for Health, Mr Ashwini Choubey informed Rajya Sabha that nearly 65 lakh patients were provided treatment worth Rs 9,549 crore under the Centre's flagship programme, Ayushman Bharat Pradhan Mantri Yojana (AB-PMJAY) till December 5, 2019.
In fact, it is a commendable achievement to cover a huge population in a short span of time, after the launching of the scheme. The news piece in the daily and the statement of the minister in the Upper house, carry a common thread and brings forward two important facets related to one aspect- health insurance in India. While the latter put forward what we have achieved, the former reminds us of what is left out to be done. In order to move ahead, and to realize the task at hand, it is pertinent to understand the nuances of this prestigious flagship programme of the Government of India and the challenges that it confronts on its way.
Prime Minister Narendra Modi announced from the ramparts of the Red Fort during the Independence Day celebrations, last year that Pradhan Mantri Jan Arogya Abhiyaan, also known as Ayushman Bharat shall be launched on 25 September 2018 on the eve of the birth anniversary of Pandit Deen Dayal Upadhyay. This scheme is also known as the National Health Protection Mission (AB-NHPM) or Modi Care. It is being hailed as the world’s largest health insurance scheme, Ayushman Bharat is expected to provide a cover of Rs 5 lakhs per family per year for secondary and tertiary medical care facilities, specified and other unspecified medical and surgical procedures. Eligibility of the potential beneficiaries is based on the Socio-Economic Caste Census (SECC) database. As one year is completed after the launch of this scheme recently, numerous challenges come ahead, that need to be dealt with the utmost sensitivity.
Challenges Ahead:
The major challenge faced by the AB–PMJAY is the menace of corruption. As this scheme completed one year recently, the corrupt practices came to the forefront and it has been highlighted by the Minister of State for Health in Rajya Sabha recently that many hospitals have been served notices in this regard. According to official figures, there are nearly 1,200 hospitals that involved in fraudulent activities in the last year, where investigations have been completed on 376 hospitals and 06 FIRs have been lodged so far. In addition to this, penalties worth Rs.1.5 crore has been levied on various hospitals and 97 among them have been delisted from this scheme. These figures only highlight the deep-seated issues related to corruption in this scheme that involves private hospitals and calls for a more stringent regulatory and supervisory mechanism in place.
Besides corruption, the second issue is related to private hospitals, which is more of a dichotomy. On one hand, many private hospitals complain that the rates fixed for various treatments are too low when compared to market rates. On the other hand, few studies prove that the state of affairs with respect to the facilities offered by the private hospitals are abysmally low. For instance, nearly 71 per cent of the hospitals enlisted under this scheme have less than 25 beds and moreover they offer only non-specialized medical services.
Tamil Nadu offers a better solution for this type of peculiar problems. It is known for a strong public health system. When the public sector health care is robust and strong, the Governments will have a higher hand in bargaining the prices for various health services with the private sector and thus the private sector too will yield to it. On the other hand, the private sector too will compete with the public sector, in order to provide better services at affordable prices, and in the end, the recipients, i.e., the ordinary citizens will be the major beneficiaries. In addition to all these benefits, a strong and efficient public health care system in place will attract a larger number of patients and as a result, they will be paid a larger portion of funds, instead of making lump-sum payments to the private hospitals. This eventually helps to strike a balance between the welfare objectives of the Public sector and the profit-making aspirations of the private sector.
The third challenge is the beneficiary empowerment, through awareness campaigns and supporting them with the necessary institutional framework. The recent steps in this direction, by the Government of India, are laudable, for establishing a system to generate e-cards for the beneficiaries. The feedback system has also been initiated, which shall exert pressure on the service providers.
The fourth challenge that is being confronted by the Aysuhman Bharath scheme is its requirement of a large base of institutional setup and meeting the expenditure to be incurred upon them. For instance, according to the implementation plan of this scheme,1,20,000 community health officers will be appointed by the financial year 2022 and it is also planned to create 1,50,000 Health and Wellness Centres by the same period.
Now the challenge is to meet this expenditure at a time when the economic growth had slowed down to less than 5 per cent. Even if the growth rate is nearly seven to eight per cent, spending nearly two per cent of GDP is ideal to reach such targets. Now in the backdrop of the economic slowdown, it is a herculean task to mobilize the funds to realize the goals of the scheme. On the other hand, states also have the prerogative to meet their respective expenditures on health.
However, they too are facing the wrath of the present economic slowdown and many states are having trouble with their fiscal balance. It is in this context, it is pertinent to note that, India’s health care system has been ranked at 145th place out of 195 countries, by the ‘Lancet’, the world’s prestigious journal. The status of India in terms of health care is worse than countries like Syria and North Korea and worse than the Philippines and Sri Lanka. With such a health care system in place, it is a Herculean task to provide quality health care facilities, which requires larger spending on the health sector in the first place.
The Government of India aims to increase the expenditure on public health to 2.5 per cent of GDP by 2025. It is a long way from the present state of around one per cent of GDP and, the country is at a point where sustaining economic growth itself is a big challenge. Coping with this increased expenditure and funding it by attracting investments, is going to be a major and immediate challenge in front of the Centre and the states as well and they need to brainstorm over the strategies to overcome this challenge efficiently.
Last but not least, the fifth challenge is the quality of the expenditure that is made and on the health care and its ability to include the socially and economically marginalized sections of the society. Thus it is not just the quantity of spending that matters but what matters most is its quality, composition and the eventual beneficiaries from such spending. To put it simply, on what it is spent and on whom it is spent matters more than the question of how much is spent.
Policy elite needs to emphasize on this aspect when they design policies to address the issue of health care in India, particularly in the wake of the reports pointing out the deep-seated inequalities in access and affordability to health care, depending on the socio, the economic and demographic background of the beneficiaries. The point to be driven home in this context is that while we need to be proud of the achievement we made in the last one year, it is equally pertinent to not be complacent and in fact need to have the task cut out, for the future course. In fact, it is also time to rethink of the strategies to broaden the coverage and ensure that the insurance cover reaches the needy and the deserving population.
Thailand Shows the Way:
Thailand’s model of Universal Health Care offers important lessons for developing countries like India. Thailand's population of 68 million is served by 927 government hospitals and 363 private hospitals with 9,768 government health centres plus 25,615 private clinics.
According to the World Bank, under Thailand’s health schemes, 99.5 per cent of the population have health protection coverage. It introduced the universal coverage reforms in 2001 and later on improved upon their efforts to make the scheme more comprehensive. As a part of it, the Government introduced the 30 baht project, in line with the small co-payment charged for treatment. Those who join this scheme gets a gold card, which allows them to access services in their health district and, if necessary, to be referred for specialist treatment elsewhere.
Universal health care is provided through three programs: the civil service welfare system for civil servants and their families, Social Security for private employees, and the universal coverage scheme. A large share of health financing in Thailand comes from private sources, in addition to public revenues. The annual funding is allocated based on the population, to contracting units for primary care.
Despite the challenges of rising costs and inequalities, Thailand still is a poster child of the cheap cost universal health coverage and stands as a role model for middle-income countries, to provide affordable health care to their citizens.
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