The United States has one of the most prodigal health systems, but this does not help the U.S. with the well-known reality that it is infamously poor-performing. And so does the fact that it is also one of the most intricate of health systems across the globe.
Over a century, U.S. health care has seen numerous elaborate arrangements, from organisational and regulatory structures to payment mechanisms emerge, be dismantled, and reincarnate with even greater degrees of complexity. Health care has repeatedly topped the political agenda; been an area of passionate contention among an unexampled plethora of diverse interest groups; and scarcely ever been an unpopular topic of national discourse. However, fervent attempts to reconcile its health care with traditional American values of individual freedom and consumerism have not sat well with the ideals of equity and social justice.
Piggyback route
In India, multiple policy pronouncements over the last few years have expressed an implicit intent to emulate certain features of the U.S. health system, enhance private initiative, and uphold the insurance route as the way to go for health care. These are being largely envisaged while riding on the back of the Ayushman Bharat-National Health Protection Scheme (AB-NHPS), which aims to provide insurance cover to nearly 50 crore poor Indians. With the great razzmatazz that characterised its launch, the AB-NHPS affirmed strong mechanisms to check insurance fraud which was commonplace in its precursor programme, the Rashtriya Swasthya Bima Yojana (RSBY). In the scramble to succeed at this, deleterious emulation of the U.S. example appears to have already set in.
Recently, 171 hospitals were reported to have been de-empanelled from the AB-NHPS on charges of fraud, which also included the issuance of fake e-cards and the manipulation of claims. A first information report was lodged against a few hospitals and multiple show cause notices were issued. This was almost within a year of the programme being launched with the promise of offering a religious check on fraudulent practices.
The response to these has been envisaged through an unprecedented bolstering of administratively-heavy and technology-driven mechanisms. Already, national- and state anti-fraud units have been established and partnerships with fraud control companies conceived. One would ask this question: what is wrong in all of this?
Let us return to the U.S. once again. Multiple layers of complex arrangements and concomitant complex regulatory provisions have ensured that health care in the U.S. is one of the most administratively and technologically intensive systems in the world. More than 50% of health-care spending in the U.S. in 2010 went into health worker’s wages, with a large chunk of the growth in health-care labour taking place in the form of non-clinical workers. What this entails is that for every penny spent on health care, very little goes into actually improving health.
Range of concerns
In India, the path of the AB-NHPS appears indistinguishable from the former, though only more menacing. It necessitates a battery of new structures, personnel cadres, data systems, and working arrangements only in order to sub-satisfactorily operate an insurance scheme that would cover less than half the population. Disregarding the death spiral that policy-driven over reliance on private health care could lead to — given India’s feeble regulatory architecture — this would entail considerable costs which would not primarily contribute to, or be indispensable for, improving health outcomes. And this is set in a context where public health spending fails to exceed a single per cent of GDP (antipodal to the U.S.) and where each rupee spent on health is highly precious. While a besottedness with cutting-edge technology and state-of-the-art systems can help garner eyes and promote businesses, each unnecessary penny incurred this way raises significant ethical concerns when basic health needs remain unmet and abject shortages of fundamental health resources and infrastructure stare square in the eye.
Gupta and Roy have shown how the allocation for the AB-NHPS for 2019-20 would have covered less than a quarter of the targeted beneficiaries. For 2020-21, there has been a paltry increase in health-care sector allocation (5.7% above 2019-20 RE), while the allocation for the AB-NHPS is unchanged. It is very possible that the AB-NHPS continues to remain insufficiently funded and incapable of extending considerable financial risk protection to the poor. However, more investment is not necessarily merrier in this context. Embracing the complexities associated with robust regulation of the insurance programme and making the requisite technological and administrative investments appear attractive and commendable on the face. However, they entail diverting highly limited resources towards wasteful and dispensable high-end areas, which could have been set aside for much more pressing and productive domains, such as public hospitals and health centres. Improvements in these areas would have strongly reflected in terms of tangibly better health outcomes. Rather, the AB-NHPS appears attuned to reinforcing a stark contradiction wherein trailblazing but unproductive high-end structures thrive alongside decrepit but potentially fructuous basic structures. In line with the suggestions of experts and critics, it becomes essential to take a fresh, hard look at the larger question of whether adopting the insurance mode for achieving universal health coverage is a felicitous path for India.
The grandiloquent fanfare with which the AB-NHPS has been rolled out and the global hype it has generated can readily adumbrate the pressing concerns that lie underneath, while floating the mistaken impression that much is being done for health care in the country. One persistent habit that has characterised Indian health care since inception is of leaping onto the next, more aspirational position or endeavour before doing sufficient justice with the previous one, thus leaving the basics unattended. The AB-NHPS, in the presence of this vice, can only be another precarious rung in the ladder.
Dr. Soham D. Bhaduri is a Mumbai-based doctor, health-care commentator, and editor of the journal, ‘The Indian Practitioner’
