The centre has introduced “Ayushman Bharat” as an ambitious mass health insurance scheme, that intends to cover about 50 crore people.
But its implementation will be more challenging than other initiatives as it would involve huge funds and infrastructure creation.
What is the medi-care landscape in India?
A nation’s development and growth is gauged by the health of its population.
But even after 70 years of independence, 80% of the Indian population is not covered under any health insurance scheme.
Additionally, the cost of medi-care is very high in comparison with the average income of the population, which makes it unaffordable for many.
Hence, the announcement of the ‘National Health Protection Scheme’ (NHPS) under ‘Ayushman Bharat Programme’, in the Union Budget 2018-19, is timely.
While the government has intended to provide free care to about 40% of the population at one go, it is impossible to do this with the existing facilities.
Notably, this has been touted as the world’s largest government-funded healthcare program and the sheer scale of the proposal is intimidating.
What is the scale of infrastructure enhancement required?
Worldwide, most governments have achieved near universal coverage by spending somewhere between 5-12% of their GDP.
For countries with large population, it takes a minimum of 5-10 years to achieve 100% coverage as health cover can’t be extended at a stretch.
It has been estimated that to achieve universal health coverage by 2022, Indian government would need to allocate 3.7-4.5% of GDP for health.
This is almost 4 times the present 1.4% and the also the bed-to-population ratio needs to be almost doubled from the current 0.9 (per 1000 people) to 1.7.
It is to be noted that considerable improvements in primary care would also result in reduction of the hospitalisation rate.
Also, we would need an additional 9 lakh graduate doctors for primary care and around 1.2 lakh specialist doctors for secondary and tertiary care services.
What are the challenges?
Profitability - The hospital business, particularly the multi-speciality tertiary care business, is capital-intensive with a long gestation period.
While infrastructure is already severely short (particularly in Tier II and Tier III cities), even existing operating assets aren’t delivering the expected returns.
Hence, the government should provide adequate finances for the sector’s development and also provide incentives and tax benefits.
Financing - Another challenge is that health is a state subject and hence requires states to contribute 40% of the expenditure for Ayushman Bharat.
Notably, most states have a poor fiscal situation, and several operational state health schemes which will also have to be aligned with the central initiative.
The model for empanelling providers would be critical to the success of NHPS and a shared space for both public and private care providers is ideal.
Implementation - Even in the previous public health insurance schemes of some states, the private healthcare providers have been facing huge challenges.
Particularly, improper procedure for empanelment, cost fixating mechanisms and inordinate delay in reimbursement to hospitals are some issues.
Also, a proper mechanism for standardisation of services across the spectrum is absent and the current ‘National Accreditation Board for Hospitals’ (NABH) certification covers only some hospitals.
What needs to be done?
Standardisation - NABH needs to categorise hospitals into Entry level, Progressive level and Accreditation level to cover all hospitals.
To improve clinical and operational efficiencies, standardisation in clinical practice and other processes needs to be implemented.
Claims Disbursal - National Costing Guidelines and a standard costing template should be used for calculating reimbursement packages.
Framing of referral protocols, adoption of electronic health record standards and clinical audits in all hospitals are other aspects that need to be done.
Successful medical claims management is also very important under any insurance programme and fraud control mechanisms should also be done.
Others - Integration of technology at each level of the healthcare continuum such as tele-medicine, health call-centres, tele-radiology etc, is needed.
For strengthening the healthcare professionals, skilling, re-skilling and up-skilling programmes for existing as well as additional workforce can be done.
A Grievance Redressal Forum should be created to ensure timely resolution of complaints without intervention of civil or consumer courts.
The government should also encourage and recognise transparency, self-regulation and third party ratings and reward clinical outcomes.
