Is Ayushman Bharat – The much needed healthcare revolution for the country?

Despite India growing economic clout and growing stature in the world, we have been left far behind as far as healthcare for the citizens in concerned.

The need of the hour in India is a Universal health cover for the common man in tune with Medicare of the USA and NHS of UK.  Unfortunately, so far most of the healthcare costs in our country is out of pocket expenses which have driven a large number of people into poverty.  It is also important to note that more than three quarters of tertiary healthcare is in the private sector and beyond the reach of the common man.

We have done quite poorly in the some of the healthcare indices and studies show India’s position to be at 162 among 195 countries based on death rates of 32 diseases that are fully amenable to treatment.  The country’s consistent un-impressive position on healthcare needs an evaluation of 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 generalized approach to health, limitations of policies, and discrepancy in healthcare for rich versus the poor and the urban versus 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.

Ayushman Bharat

The National Healthcare Protection Mission or NHPM (Ayushman Bharat) is the most ambitious healthcare program ever launched in any country with coverage being offered to a 100 million poor families (almost 500 million people far more than the populations of the USA or Europe).  

Ayushman Bharat will empower the needy 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 in hospitals to about 50 crore poor and vulnerable population for primary care – basic services usually provided by general practitioners or nurses – the government plans to open 150,000 “health and wellness” centers, staffed by nurses, traditional medicine healers and other health workers, by 2020 and a plan to upgrade existing sub-centers into Health and Wellness Centers across the country. Ayushman Bharat promises to unlock the freedom of health for all.  However, limitations of the mission remain.

A scheme of this magnitude would be very challenging and certainly a herculean task to implement.   The main problems I see in implementing this would be the need to build an enormous infrastructure, health care personnel and finances.

Financial Issues

One of the main challenges to the National Health Protection Scheme (NHPS) is financing. Conservative estimates by official sources have estimated that the scheme would require at least Rs.1 trillion annually for successful implementation.  

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.

Infrastructure Issues

A good healthcare system needs more than money.  It needs more and better doctors and nurses, clinics and hospitals.  It needs more primary health facilities, distributed evenly throughout the country within reach of low-income families.  It needs an increase in health research geared to India’s epidemiology.  The government needs to mount a public education campaign that reaches ordinary people.  Instead of producing more super-specialty doctors and hospitals, it needs doctors who deal with day-to-day medical ailments and prophylaxis.  It also needs doctors and medical staff who actually listen respectfully to patients about their bodies and physical and mental worries.   This means revamped medical education and not just more doctors, medical colleges, clinics and hospitals.

Support of the Private Healthcare Sector

The other challenge would be the acceptance of the financial model by the private healthcare sector since the reimbursements are far less than their charges currently.  Since the tertiary care is largely in the private sector a serious dialogue and a private public sector partnership with a reasonable reimbursement would have to be worked out.

For Ayushman Bharat to work will require a massive galvanizing of healthcare.  It will require careful coordination with private healthcare providers.  What kinds of rates can the government and private providers agree upon?  Having agreed, will private clinics and hospitals deal with poor patients who bring in relatively low payments, or will they deal mostly with richer patients?  Though the current reimbursement model for many procedures seem abysmally low we do hope that as the system matures reimbursement rates will be rationalized and in the larger interest of the society private players and the government will work together to make this work.

The opportunities for graft could be enormous: providers could conjure up patients and make claims on the government program for payment.  This will require a very robust auditing mechanism to hold care givers accountable.

Focus on “Creating Wellness rather than Treat Illness”

We need to clearly distinguish the two modalities of modern medicine to keep citizens healthy – public health (create wellness) and disease-care (treat illness).  Public health is what the state does to prevent disease and to protect health.  In contrast, disease-care includes the different types of interventions that are carried out to restore health after an individual falls ill.  Certainly the government needs to focus on preventive and primary care far more than spending on tertiary care and this would save a lot more lives at a fraction of the cost.  The wellness centers planned by the government is a move in the right direction.   I do believe public healthcare system should heavily invest in preventing and protecting one’s health and this could be measures to prevent communicable diseases and cut down burden of non-communicable diseases which have overtaken communicable diseases in the mortality statistics.

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 measures to make it conducive for an active participation by the private sector.

All in all we had to start somewhere and Ayushman Bharat is hopefully the beginning of universal healthcare for the 1.3 billion citizens of our country.  A lot of hurdles have to be crossed and many modifications may need to be made for us to reach our destination but I do hope it will be a very fruitful and worthwhile journey for all of us.

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