Announcements made in this year’s Union Budget suggest that the long-awaited recognition by the government of its duty to provide healthcare to all citizens and ensuring financial risk protection has arrived. More interesting than the announcement itself is the agility with which the prime minister’s name has been prefixed to the scheme (Modicare, lifted from US Medicare or Obamacare) by his handlers, which seems to suggest that the PM is willing to spend some of his personal political capital on this scheme.
Although the details are missing, the scheme seems ambitious in scope and acknowledges that the health of citizens of India is a national asset. Healthcare expenditure is a major cause of poverty in India and it is the responsibility of the government to address it. It has been repeatedly stressed that it is essential to have a healthy workforce for India to realise the full potential of its ‘demographic dividend’ in terms of economic growth. It would be churlish to not welcome the recognition of this principle.
However, we should examine what can derail the application of this idea. The first source of worry is the paltry sum that has been allocated for the proposed National Health Protection Scheme, as pointed out very quickly by analysts. A charitable explanation for this is that perhaps most of the first year will go into planning how to execute the scheme, and the big allocations will come in subsequent years. We will have to wait and see.
More disappointing, however, is the suggested direction for implementation – by using an insurance model which favours the private sector – rather than strengthening the public healthcare system. This is a lazy and unsustainable solution at multiple levels, more so with regards to primary care delivery and management of chronic conditions, which are the largest and fastest-growing causes of death and disability in India.
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State-funded insurance schemes in India have focused on curative healthcare (procedures that are done in hospitals) through private hospitals rather than prioritising preventive healthcare or strengthening public sector facilities. While such models may be effective in taking care of conditions that require a one-time encounter with the healthcare system, such as a curative surgery or intervention, experience from insurance schemes implemented in a few states suggests that the quality of care and outcomes in chronic disease management are far from optimal.
Data also suggest that merely removing the financial barrier at the point of care delivery is not enough to eliminate out-of-pocket expenditure and remove inequities in access to care. Unless these issues are addressed forthwith, the disenfranchisement of the already marginalised is likely to increase further.
It is important that whatever delivery model is implemented, it keeps access and equity front and centre. There are a number of reasons why private sector would not contribute to this goal. One can already sense the private sector straining at the leash, looking at the possibility of using this scheme to develop a referral mechanism to funnel patients from the community to their hospitals.
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It is important that the guidance framework to implement whatever system is developed takes into account the available evidence around effective, sustainable and affordable healthcare delivery, examines all models of care and develops delivery mechanisms that bring healthcare at the doorsteps of the people who need it, rather than requiring that they approach the system when they feel they need to.
Task-shifting, use of technology and digitisation provide powerful opportunities and must form the backbone of new care delivery models. This can only be done using public sector delivery – it would be a pity if in the guise of insurance schemes public sector is allowed to atrophy.
Irrespective of the pros and cons, the most important contribution of the finance minister’s Union Budget speech is that for the first time, healthcare seems to have come to the forefront of public debate arena in India. It is important for all the stakeholders to ensure that this conversation stays alive. It is impossible to say how long it might take to reach a stage where access to essential equitable healthcare becomes a reality for a majority of the population, but we seem to have made a start.
Vivekanand Jha is the Executive Director of the George Institute for Global Health India and a Professor of Nephrology at University of Oxford.