25 June 2018
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As the Union government gears up to launch the National Health Protection Mission (NHPM), questions around how desirable a prescription it is for India continue to be asked. Debating them objectively to draw lessons from the experience of last few years of implementing publicly run health insurance schemes across states can be useful, as the MoUs with states are being worked out.
Under the government’s vision of Ayushman Bharat NHPS, beneficiaries from 10 crore poor and vulnerable families will receive an insurance cover up to Rs 5 lakh annually per family for inpatient secondary and tertiary care. Such advanced care will be provided by empanelled government and private hospitals through a ‘strategic purchase’ mechanism. Beneficiaries will be selected on the basis of ‘deprivation and occupational’ criteria from the Socio Economic Caste Census. An upscaled model of Rashtriya Swasthya Bima Yojana (RSBY), the first national health insurance scheme that came in 2008, NHPS is designed to be fully subsidised by the Centre and state government through their budgetary support.
Out of pocket (OOP) expenditure to pay for healthcare costs is a big problem in the country. About 63% of health spending in India is through OOP payments. This is substantially high, pushing about 7% population below poverty threshold every year. Previous experiences have shown that targeted government financed health insurance has not led to any significant reduction in OOP expenditure. A relative reduction in OOP expenditure was seen only under the state health insurance scheme in undivided Andhra Pradesh, however it was concentrated on the richest 60% segment, implying inequitable effect of the state supported health insurance.
Expenses associated with chronic and non-communicable diseases (NCDs) that necessitate prolonged consultations at OPD, and which form a higher percentage of OOP expenditure are excluded from NHPM. About 70% percent of health care burden on families is due to spending either on medicines for common ailments which can be prevented, like cold, fever, headache, or from managing illnesses which are chronic , like heart diseases, TB, respiratory tract infections e.g. Asthma, where hospitalisation is a one off event. Hence the present shape of the scheme has a limited utility for its beneficiaries.
An EPW article has discussed that under the Mahatma Jyotiba Phule Jan Aarogya Yojana (MJPJAY) in Maharashtra, insurance services worth Rs. 1,880 crore were purchased by paying Rs. 2,350 crore by the state government. If scarce public resources are consumed by high end secondary and tertiary care envisaged under NHPM, how can a robust primary and preventive health care be financed? The real solution lies in stepping up public spending on health; else any meaningful hike for one scheme would be balanced by a cut elsewhere. Just as the allocation of Rs. 2,000 crore for NHPM in Union Budget 2018-19 came with a reduction of 2% in the budget for NHM, the flagship programme for strengthening primary healthcare machinery in the country.
Delivering primary healthcare to its citizens is government’s basic responsibility. As a solution to bring essential primary healthcare services closer to people, NHPM is supposed to be complemented by establishing 1.5 lakh health and wellness centres. If the system is galvanised properly through adequate training of nurses to take charge of these centres, the plan has the potential to deliver basic health services. The challenge of equipping the centres with necessary infrastructure, suitable skills and regular supply of essential drugs can be met only with dedicated efforts and a robust financing.
As countries take steps to get closer to UHC, NHPM should have been conceived in a way to protect all Indians while prioritising the poor. Contributions could have been applied in the scheme design with the understanding that those who make contribution will benefit from the government subsidy and won’t be burdened with OOP costs as in present.
Most countries implementing health insurance for their citizens provide it as a means to further the end of a more equitable society through universal health care. Importance of all people having access to quality health services without risking financial hardship is enshrined as a goal in the SDG agenda also. Moving towards Universal health care (UHC) system requires strengthening the public health system. Benefits of public health insurance schemes cannot be reaped unless the basic health care infrastructure for delivery of primary health services is strong, notes a recent study.
All insurance based health strategies witness escalating costs as they result in profits for private sector, however when governments pay for health care, they work to ensure doctors and hospitals provide quality care at a reasonable cost. No country can manage to provide healthcare in an equitable manner without an efficient public health system. Even if strong regulation and effective safeguards are implemented to check that the scheme does not end up supporting expansion of private insurance and hospital sector, true gains can be made only if the government invests in strengthening of our public health system.
The views expressed in this piece are those of the author, and don’t necessarily reflect the position of CBGA. You can reach Happy Pant at happy@cbgaindia.org.