Universal health coverage is getting prioritised as a part of political reform with the launch of two pillars of the Pradhan Mantri Jan Arogya Yojana (PMJAY): Ayushman Bharat (AB), where 1.5 lakh health sub-centres are being converted into health and wellness centres; and the National Health Protection Mission (NHPM), which aims to provide health cover of ₹5 lakh per family, per annum, reaching out to 500 million people.
The “best health care at the lowest possible cost” should be: inclusive; make health-care providers accountable for cost and quality; achieve a reduction in disease burden, and eliminate catastrophic health expenditures for the consumer. All of this is not happening overnight simply because an audacious, nation-wide health-care programme is on the anvil. It could come about, however, if accompanied by the nuts and bolts of good governance that will support solutions and systems to achieve these objectives.
Align entitlement to income
In the matter of inclusion, over 15 years ago, the Vajpayee government commissioned the Institute of Health Systems (IHS), Hyderabad to develop a ‘family welfare linked health insurance policy’. In 2003, the Director of the IHS Hyderabad delivered a broad-based Family Health Protection Plan (FHPP), open to all individuals. The fact is that any discourse on universal health care in India gets stymied by the sheer size and ambivalence of the numbers involved. This 2003 solution of the Vajpayee-era recommended, inter alia , that good governance lies in aligning the income lines for health and housing. In other words, de-link entitlement to health care from the poverty line. In that event, the income lines for housing (updated from time to time), could be simultaneously applicable for health entitlement. The government could then proceed, as per capacity, to scale the health premium subsidy in line with housing categories — economically weaker sections (entitled to 75-90%), lower income (entitled to 50%), and middle income groups (entitled to 20%).
Build in accountability
The NHPM is pushing for hospitalisation at secondary- and tertiary-level private hospitals, while disregarding the need for eligible households to first access primary care, prior to becoming ‘a case for acute care’. We are in danger of placing the cart (higher-level care) before the horse (primary care). Without the stepping stone of primary health care, direct hospitalisation is a high-cost solution.
Last month, the Union Minister for Health and Family Welfare, J.P. Nadda, said that while the PMJAY would help improve availability, accessibility, and affordability for the needy 40% of the population, the Prime Minister was looking for one additional requirement — that the PMJAY must continue to maintain credibility.
This leads me to a caveat. Public sector health capacities are constrained at all levels. Forward movement is feasible only through partnerships and coalitions with private sector providers. These partnerships are credible only if made accountable. The National Health Policy 2017 proposed “strategic purchasing” of services from secondary and tertiary hospitals for a fee. Clearly, we need to contract-in services of those health-care providers (public and private) who are assessed as competent to provide all care for all the medical conditions specified; who will accept and abide by standard treatment protocols and guidelines notified, as this will rule out potential for induced care/unnecessary treatment; and who will accept the AB-NHPM financial compensation package (with fixed fees per episode, and not per visit).
The credo for participating private providers should be “mission, not margin”. Health-care providers (public/private) should be accredited without any upper limit on the number of service providers in a given district. The annual premium for each beneficiary would be paid to those service providers, for up to one year only (renewable), as selected by beneficiaries. The resultant competition would enhance quality and keep costs in check. Upgrading district hospitals to government medical colleges and teaching hospitals will enhance capacities at the district level. Service providers will become accountable for cost and quality if they are bound to the nuts and bolts of good governance outlined above.
Transform primary care
Third, elimination of catastrophic health expenditures for the consumer can come about only if there is sustained effort to modernise and transform the primary care space. Bring together all relevant inter-sectoral action linking health and development so as to universalise the availability of clean drinking water, sanitation, garbage disposal, waste management, food security, nutrition and vector control. The Swachh Bharat programme must be incorporated in the PMJAY. These steps put together will reduce the disease burden.
At the 1.5 lakh ‘health and wellness clinics’ (earlier, health sub-centres), register households to provide them access to district-specific, evidence-based, integrated packages of community, primary preventive and promotive health care. A public education media campaign could highlight the merits of personal hygiene and healthy living. Kerala and Tamil Nadu have demonstrated that high-performing, primary health-care systems do address a majority of community/individual health needs. The health and wellness clinics must connect with early detection and treatment. The cornerstone of the Vajpayee-era FHPP was the primary medical clinic providing ambulatory primary care, out-patient consultation, clinical examination, curative services, and referrals. Robust delivery of preventive, clinical and diagnostic health-care services will result in early detection of cancers, diabetes and chronic conditions, mostly needing long-term treatment and home care. This will further minimise the demand for hospitalisation. Investment in primary care would very quickly reduce the overall cost of health care for the state and for the consumer.
Technology and innovation are further reducing costs. AI-powered mobile applications will soon provide high-quality, low-cost, patient-centric, smart wellness solutions. The scaleable and inter-operable IT platform being readied for the Ayushman Bharat is encouraging.
As we integrate prevention, detection and treatment of ill-health, the PMJAY will win hearts if people receive a well-governed ‘Health for All’ scheme.
Meenakshi Datta Ghosh is former Secretary in the Union Ministry of Panchayati Raj, and Special Secretary, Ministry of Health and Family Welfare