Context Recently, Prime Minister Narendra Modi while addressing the first-ever high-level meeting on Universal Health Coverage in Newyork, said his government has taken some historic steps like the world's largest health insurance scheme - Ayushman Bharat - to provide access to affordable health care services to all. Meaning of healthcare
- Heath is not the mere absence of disease. Good health confers on personal freedom from illness - and the ability to realize one's potential. Health is, therefore, best understood as the indispensable basis for defining a person's sense of well-being.
- Health care covers not merely medical care but also preventive care too. Nor can it be limited to care rendered by the government sector alone but must include self-care and private sector.
- The Constitution guarantees fundamental rights to its people. Article 21 gives the citizens the Right to Life.
- Many other obligations are listed under Directive Principles of State Policy. These include Article 47, 39 and 38, which argue for the need to raise the level of nutrition, enhance standards of living and improve public health. They also make a case for social justice and sustainable livelihoods.
What makes for a just health care system ?
- First, universal access, and access to an adequate level, and access without excessive burden.
- Second, fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity.
- Third, training providers for competence empathy and accountability, pursuit of quality care and cost effective use of the results of relevant research.
- Fourth, special attention to vulnerable groups such as children, women, disabled and the aged.
Some important facts and figures on health sector in India
- Public expenditure: Public expenditure on health is 1.4% of GDP.
- Household expenditure: 70 percent of the overall household expenditure on health in the country is on medicines
- Access to essential medicines: Around 470 million people in India do not have regular access to essential medicines.
- Healthcare facilities: Around 60% of primary health centres do not have an operation theatre and 30% lack a labour room, community health centres are short of 80 % specialists–surgeon, gynecologists and pediatricians.
- Inpatient care: Around 60% Indians use private facilities for inpatient care.
- Out-of-pocket expenditure: Rising out-of-pocket expenditures on healthcare is pushing around 40 million Indians below the poverty line annually.
- Heart disease: Heart disease (1/4 people) and stroke is the biggest killer of men and women in India.
Issues with healthcare in India
- Low healthcare spending: India spends less on healthcare than other middle-income countries. At 1.4 per cent of total GDP expenditure on healthcare, spending on health care is half that of Brazil, South Africa and much lower than China and Russia.
- Public share of healthcare expenditure remains low: Public spending on healthcare in India, at 33 percent of the total healthcare spend,is one of the lowest in the world in spite of the fact that a quarter of Indian population lives below poverty line.
- IMR still among the highest amongst peers:Even with healthcare advancements and government programs, Infant Mortality Rate (IMR) at 33 is still among the highest in India when compared to other emerging economies.
- Maternal health safety still an issue: India still accounts for 20 per cent of maternal mortality deaths in the world with 130 deaths per 100,000 live births. The number is a result of low share of institutional deliveries.
- Scarcity of beds remains a big challenge: Although India has witnessed the advent of several major hospital chains in the last decade, the total bed capacity still remains far from sufficient. Indian hospital bed to population ratio at less than1 per thousand is the lowest among all BRICS countries.
- Human resource shortage: Lack of skilled service providers is one of the biggest constraints in India. There is only 1 doctor per 10,000 people. The condition deteriorates as one moves from urban to rural areas. About 80 per cent of doctors present in urban areas when 70 per cent of India’s population lives in rural areas.
- Increasing affordability issues: Rising healthcare costs is another major concern for India, with around 60 per cent of the healthcare expenditure being out of pocket. Low insurance coverage and weak public healthcare system are driving up the average cost for healthcare and especially creating a burden for those with limited means.
Factors that make health care unaffordable in India
- Low government contribution: Indian healthcare suffers from low public contribution to healthcare expenditure which contributes to only one-third of total spending.
- High private share: Private share constitutes 70 per cent of overall expenditure. This creates a huge gap in healthcare funding leading to increase monetary burden on individual with no social coverage from government.
- Low penetration of insurance: There is low penetration of private health insurances as currently around five percent of healthcare expenditure is being financed by insurances.
- OOP remains a major source: OOP(out of pocket) contributes close to 86 percent of private expenditure and 60 percent of overall healthcare expenditure. Nearly 40 million people in India are in debt because of out of pocket expenditure on health.
National Health Policy National Health Policy of the country was released in 2017 after a gap of 15 years. It consists of the following main features:
- Assurance based approach: The Policy advocates progressively incremental assurance based approach with focus on preventive and promotive healthcare
- Health Card linked to health facilities: The Policy recommends linking the health card to primary care facility for a defined package of services anywhere in the country.
- Patient Centric Approach: The Policy recommends the setting up of a separate, empowered medical tribunal for speedy resolution to address disputes /complaints regarding standards of care, prices of services, negligence and unfair practices, etc.
- Micronutrient Deficiency: There is a focus on reducing micronutrient malnourishment and systematic approach to address heterogeneity in micronutrient adequacy across regions.
- Quality of Care: Public hospitals and facilities would undergo periodic measurements and certification of level of quality. Focus on Standard Regulatory Framework to eliminate risks of inappropriate care by maintaining adequate standards of diagnosis and treatment.
- Make-in-India Initiative: The Policy advocates the need to incentivize local manufacturing to provide customized indigenous products for Indian population in the long run.
- Application of Digital Health: The Policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and aims at an integrated health information system which serves the needs of all stake-holders and improves efficiency, transparency, and citizen experience.
- Private sector engagement: Private sector engagement for strategic purchase for critical gap filling and for achievement of health goals.
Govt. schemes for affordable health care
- Rashtriya Arogya Nidhi (RAN): The RAN was set up in 1997 to provide financial assistance to patients, living below poverty line and who are suffering from major life threatening diseases, to receive medical treatment at any of the super speciality Hospitals/Institutes or other Government hospitals. The financial assistance to such patients is released in the form of ‘one-time grant’, which is released to the Medical Superintendent of the Hospital in which the treatment has been/is being received.
- Pradhan Mantri Swasthya Suraksha Yojana (PMSSY): PMSSY was announced in 2003 with the objectives of correcting regional imbalances in the availability of affordable/ reliable tertiary healthcare services and also to augment facilities for quality medical education in the country. PMSSY has two components:-
- Setting up of AIIMS like Institutions
- Upgradation of Government Medical College(GMC)/ Institutions.
- Rashtriya Swasthya Bima Yojana(RSBY): RSBY, launched in 2008, is a government-run health insurance programme for the BPL population. The scheme aims to provide health insurance coverage to the unrecognised sector workers belonging to the BPL category and their family members shall be beneficiaries under this scheme. It provides for cashless insurance for hospitalisation in public as well as private hospitals.
- National Health Mission(NHM): NHM, launched in 2013, encompasses its two sub-missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). NHM envisages achievement of universal access to equitable, affordable & quality health care services that are accountable and responsive to people's needs. The National Health Mission seeks to ensure the achievement of the following indicators.
- Reduce MMR to 1
- Reduce IMR to 25
- Reduce Total Fertility Rate (TFR) to 2.1
- Prevention and reduction of anaemia in women aged 15–49 years
- Reduce household out-of-pocket expenditure on total health care expenditure
- Reduce annual incidence and mortality from Tuberculosis by half
- Reduce prevalence of Leprosy to <1>
- Annual Malaria Incidence to be <1>
- Mission Indradhanush: Mission Indradhanush, launched in 2014, seeks to drive towards 90% full immunization coverage of India and sustain the same by year 2020. Vaccination is being provided against eight vaccine-preventable diseases nationally, i.e. Diphtheria, Pertussis, Tetanus, Polio, Measles, Tuberculosis, Hepatitis B and meningitis & pneumonia; and against Rotavirus Diarrhea and Japanese Encephalitis in selected states and districts respectively
- Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) was launched in 2016 to provide comprehensive and quality Ante-Natal Care (ANC) to pregnant women on the 9th of every month. Under PMSMA, doctors from both the public and private sector examine pregnant women on 9th of every month at Government health facilities.
- LaQshya: 'LaQshya - Quality Improvement Initiative' was launched in 2017 with the objectives of reducing preventable maternal and newborn mortality, morbidity and stillbirths associated with the care around delivery in Labour room and Maternity OT (Operation Theatre) and to ensure respectful maternity care.
- POSHAN: POSHAN Abhiyaan (National Nutrition Mission), launched in 2017, is a flagship programme of the Ministry of Women and Child Development (MWCD), which ensures convergence with various programmes such as Anganwadi Services, Pradhan Mantri Matru Vandana Yojana (PMMVY), etc. to achieve improvement in nutritional status of Children from 0-6 years, Adolescent Girls, Pregnant Women and Lactating Mothers in a time bound manner during the next three years beginning 2017-18.
- Ayushman Bharat:
- Ayushman Bharat, launched in 2018, is a flagship programme of the Government, which comprises of two interrelated components, viz. establishment of “Health and Wellness Centres” (HWCs) for delivering Comprehensive Primary Health Care and “Pradhan Mantri Jan Arogya Yojana” (PMJAY), a health assurance scheme for preventing the financial hardships in availing in-patient care.
- 1,50,000 sub-centers and Primary Health Centres to Health and Wellness Centres are to be upgraded by 2022 under Ayushman Bharat. This initiative is an attempt to move from a selective and segmented approach to a comprehensive need-based health care service delivery.
- The HWC would be the first point of contact with the PHC/ CHC serving as the first referral point. This would, over time, reduce the burden on secondary and tertiary centers having to provide care for primary health as well, and also reduce out of pocket expenditures.
- The second component of Ayushman Bharat, PMJAY, the largest public health insurance scheme in the world aims at providing financial protection (Swasthya Suraksha) to around 11 crore poor and vulnerable families (approx. 50 crore beneficiaries) as per the latest Socio-Economic Caste Census (SECC) data, and existing RSBY beneficiaries.
- The scheme offers a benefit cover of `5 lakh per family per year. To ensure that nobody is left out (especially the girl child, women, children and elderly), there is no cap on family size and age in the scheme.
- PMJAY covers medical and hospitalization expenses for most of the secondary and tertiary care procedures. The scheme is cashless and paperless at public hospitals and impanelled private hospitals.
- The benefits also include pre and post-hospitalization expenses. The scheme is entitlement based.
Some international best practices in healthcare
- Using collaboration to cut readmission rates: Hospitals that have forged collaborations among providers and community-based organizations and that encourage self-management have rapidly reduced readmissions.
- Adopting telehealth to boost patient outcomes: Platforms that engage patients before and after surgery produce better results than traditional approaches.
- Using software to avoid misdiagnoses: Computer-assisted diagnosis technology is underutilized, but studies suggest it can help by boosting physicians' diagnostic confidence, reducing costs and improving patient outcomes
- Residency programs for nurses: Nursing residency-type programs can help meet demand for trained nurses while cutting costs for hospitals.
- Affordable Care Act Affordable Care Act of the U.S. has helped curb runaway costs in the private sector.
- Priority sector: The government should focus on the unfinished agenda such as ‘priority sector’ status to the health sector to ensure smooth credit flow, mandatory universal health insurance, tax incentives for capacity building, creation of a dedicated infrastructure and innovation fund.
- Primary health care: In 2011, a high-level expert group on universal health coverage reckoned that nearly 70% of government health spending should go to primary health care. This recommendation needs to be followed.
- NHM: The NHM’s share in the health budget fell from 73% in 2006 to 50% in 2019 in the absence of uniform and substantial increases in health spending by States. Thus, allocation to NHM needs to be increased.
- Investment: There is a need to depart from the current trend of erratic and insufficient increases in health spending and make substantial and sustained investments in public health over the next decade.
- Learning from neighbours: India’s neighbours, in the past two decades, have made great strides on the development front. Sri Lanka, Bangladesh and Bhutan now have better health indicators than India. India must learn from them.
- Junk food: India should ban the sale of junk food in and around schools. Higher taxes on junk food can actually lead those on lower incomes to live healthier lives.
- Artificial Intelligence: Artificial Intelligence (AI) in healthcare can help to leverage technology to deploy efficient, impactful interventions at exactly the right moment in a patient’s care.
- Medical assistants: Practitioners of modern medicine (say medical assistants) trained through short-term courses, like those of a 2-3 year duration, can greatly help in providing primary health care to the rural population.
- Preventive healthcare: Focus on preventive healthcare such as special emphasis on yoga, ayurveda and fitness.
- Accessibility: The prices of heart stents were cut steeply last year. The problem of stenting however is not just about price. Improve accessibility along with price control is needed.
- Social insurance model: India could learn from the experience of Thailand, where health outcomes such as life expectancy have far outperformed India’s based on a universal healthcare coverage scheme that, since 2002, was built on a successful social insurance model.
- Right to Health: A constitutional amendment in relation to the Right to Health, similar to the Right to Education Act, should be considered
- Spending: The government needs to increase its public spending on health to at least 3 per cent of GDP, in keeping with its improved economic status.
Conclusion As the Ayushman Bharat revolution unfolds, it is hoped that India will make sure healthcare is no longer a privilege and is available to every Indian who will be assured the gift of life and good health.