Much needs to change for Ayushman Bharat to succeed

Despite India’s growing economic stature in the world, we have been left far behind as far as healthcare for citizens in concerned.

The need of the hour is a universal health cover for the common man such as Britain’s NHS or the US Medicare. Unfortunately, so far, most of the healthcare costs in our country has been borne by people out of their pockets, driving a large number of them into poverty each year. It is also important to note that more than three quarters of tertiary healthcare is in the private sector and beyond the reach of the common man.

We have done quite poorly in most healthcare indices and are placed at 162 among 195 countries, based on death rates due to 32 treatable diseases. It is time to address underlying factors, such as lack of investment in healthcare and a generalised approach to health, limitations of policies, and discrepancy in healthcare for the rich versus the poor and the urban versus the rural citizen.

Expenditure on healthcare is a major driver of poverty. An estimated 94.44 million were impoverished after incurring expenditure on medical care in 2014. About 47% of hospital admissions among rural masses and 31% among urban Indians are financed by loans and sale of assets; and 30% of the former and 20% of the latter go untreated because of financial constraints.

Ayushman Bharat

The National Healthcare Protection Mission or NHPM (now, Ayushman Bharat) is one of the most ambitious healthcare programmes ever launched, with coverage being offered to 10 crore families (about 50 crore people). It will empower the needy class of the country, a movement that can potentially change the face of medical service in India. A scheme of this magnitude would be challenging and certainly a herculean task to implement. The main problem I see in implementing this would be the need to build an enormous infrastructure, healthcare personnel and finances.

Conservative estimates by official sources show that the scheme would require at least Rs 1 lakh crore annually for successful implementation. The government had set a goal of increasing expenditure on health to 2% of GDP by 2010 in its 2002 policy. It has reached only 1.15%. Yet, the goal in National Health Policy (NHP) 2017 was increased to 2.5% of GDP. Unless health receives priority attention, the new schemes launched with much fanfare will not achieve the desired results.

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A good healthcare system needs more than money. It needs more and better doctors and nurses, clinics and hospitals. It needs more primary health facilities, distributed evenly throughout the country, within reach of low-income families. It needs an increase in health research geared to India’s epidemiology. The government needs to mount a public education campaign that reaches ordinary people. Instead of producing more super-specialty doctors and hospitals, it needs doctors who deal with day-to-day medical ailments and prophylaxis. It also needs doctors and medical staff who actually listen respectfully to patients about their bodies and physical and mental worries. This means, a revamped medical education and not just more doctors, medical colleges, clinics and hospitals.

The other challenge would be the acceptance of the financial model by the private healthcare sector, since the reimbursements are far less than their charges currently.

Since tertiary care is largely in the private sector, a serious dialogue and a private-public partnership with a reasonable reimbursement would have to be worked out.

For Ayushman Bharat to work will require a massive galvanising of healthcare. It will require careful coordination with private healthcare providers. What kinds of rates can the government and private providers agree upon? Having agreed, will private clinics and hospitals deal with poor patients who bring in relatively low payments, or will they deal mostly with richer patients? Though the current reimbursement model for many procedures seem abysmally low, we do hope that as the system matures, reimbursement rates will be rationalised.

At the same time, the opportunities for corruption could be enormous: providers could conjure up patients and make claims on the government programme for payments. This will require a robust auditing mechanism to hold care-givers accountable.

Wellness or treating illness?

We need to clearly distinguish the two modalities of modern medicine to keep citizens healthy – public health (create wellness) and disease-care (treat illness). Public health is what the state does to prevent disease and to protect health. In contrast, disease-care includes the different types of interventions that are carried out to restore health after an individual falls ill. Certainly, the government needs to focus on preventive and primary care far more than spending on tertiary care, and this would save a lot more lives at a fraction of the cost.

The wellness centres planned by the government as part of Ayushman Bharat is a move in the right direction. I do believe the public health system should heavily invest in preventing and protecting one’s health and these could be on measures to prevent communicable diseases and cut down burden of non-communicable diseases, which have overtaken communicable diseases in the mortality statistics.

All in all, we had to start somewhere, and Ayushman Bharat is hopefully the beginning of universal healthcare for the 1.3 billion citizens of our country. A lot of hurdles have to be crossed and many modifications may need to be made as we go along, but I do hope it will be a very fruitful and worthwhile journey for all of us.

(The writer is chairman, Manipal Hospitals)