On September 25, 2018, well-hyped Ayushman Bharat – National Health Protection Scheme (AB-NHPS), touted as the largest health scheme in the world, was launched in India. Prior to its launch, while announcing the scheme on August 15, 2018 from the Red Fort,Prime Minister Narendra Modi said: “The healthcare initiatives of the government will have a positive impact on 50 Crore Indians,” as it aims to provide a coverage of Rs 5 lakh per family annually, benefiting more than 10 Crore poor families.

Before this scheme was introduced, there were several public funded health schemes in India, introduced by different governments, like National Rural and Urban Health Mission (NRHM and NUHM), Rashtriya Swasthya Bima Yojana etc. Reports also capture that since independence efforts were ongoing in this area. But none worked, due to shoddy implementation. Let’s await the outcome of yet another new health scheme, introduced by yet another government – AB-NHPS.

According to the Government Press Release of January 11, 2019: Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY) aims to provide health coverage during secondary and tertiary hospitalization of around 50 Crore beneficiaries, allocating a sum of up to Rs. 5 Lakh per family per year. The key words that need to be noted is ‘the health coverage during hospitalization’. It also doesn’t cover primary care. Interestingly, some of the larger states, such as Punjab, Kerala, Maharashtra, Karnataka and Delhi are, reportedly, yet to come on board, Odisha has refused to be a part of the scheme.

Conceptually, the above new health initiative, aimed at the poor, is praiseworthy.  However, its relevance in reducing a significant chunk of one of the highest, if not the highest, ‘Out of Pocket (OoP’) expenses towards health in India, raises more questions than answers.

This is because, whether annual ‘OoP’ for health, incurred by the country’s poor population, goes more for hospitalization than Primary Health Care (PHC) involving common illnesses, is rather clear today. In this article, I shall dwell on this subject, supported by credible published research data.

But ‘the Primary Health Care (PHC) is in shambles’:

Since the focus of (AB-NHPS) on ‘secondary and tertiary hospitalization’, one may get a feeling that the primary public health care system in India is, at least, decent.

But the stark reality is different. The article titled, ‘Five paradoxes of Indian Healthcare,’ published inThe Economic Times on July 27, 2018 describes the situation eloquently. It says: ‘While the Supreme Court has held health care to be a fundamental right under Article 21 of the Constitution…The fundamental aspect of health care – the primary health care is in shambles. There is only one primary health care center (often manned by one doctor) for more than 51,000 people in the country.’

In addition, the World Bank Report also flags: ‘The tenuous quality of public health assistance is reflected in the observation that 80 percent of health spending is for private health services, and that the poor frequently bypass public facilities to seek private care.’ Although, World Bank underscored this problem sometime back, it persists even today, sans any significant change.

PHC has the potential to address 90 percent of health care needs:

For the better health of citizens, and in tandem to contain disease progression that may require hospitalization for secondary and tertiary care, government focus on effective disease prevention and access to affordable and high quality PHC for all, is necessary. ‘Evidences gathered by the World Bank have also highlighted that primary care is capable of managing 90 percent of health care demand, with only the remaining 10 percent requiring services associated with hospitals.’

Another article titled, ‘Without Primary Health Care, There Is No Universal Health Coverage,’ published in Life – A HuffPost publication on December 14, 2016, also vindicates this point. It emphasized: ‘Primary health care (PHC) has the potential to address 90 percent of health care needs. However, country governments spend, on average, only one third of their health budgets on PHC.’ The situation in India is no different, either.

This basic tenet has been accepted by many countries with ample evidences of great success in this direction. Curiously, in India, despite the public PHC system being in shambles, the government’s primary focus is on something that happens only after a disease is allowed to progress, virtually without much medical intervention, if at all.

Key benefits of a strong PHC system:

As established by several research papers, such as one appeared in the above HuffPost publication, and also by other research studies, I am summarizing below the key benefits of having an affordable and strong PHC network in the country:

• Can manage around 90 percent of the population’s health care need, patients would require hospitalization for specialists care only 10 percent of the time.

• Can help people prevent diseases, like malaria or dengue, alongside effectively assist them in managing chronic conditions, such as hypertension or diabetes, to avert associated complications that may require secondary or tertiary care.

• At the country level, a strong PHC system would help detect and screen illnesses early, offering prompt and effective treatment. The system, therefore, will support a healthier population, and would ‘offer much more than simple reduction of the costs of a country’s health.’

• A country can ensure greater health equity by providing PHC advantages of greater accessibility to the community, and across the social gradient.

• In short: ‘The continuity and doctor–patient relationships offered by family oriented primary care, alongside the patient education, early intervention and treatment, chronic disease management, counseling and reassurance offered to patients would be impossible to provide in a secondary care setting.’

Thus, establishing a robust network of high-quality public PHC facilities in the country is a necessity. Simultaneously, patients should be made aware of visiting the nearest PHC as their first stop for affordable treatment, when they fall ill.

Annual ‘OoP expenses’ more on ‘out-patient care’ than ‘hospitalization’:

For illustration, I shall provide examples from just two studies, among several others, which found, average ‘OoP expenditure’ per family in a year, is more for ‘out-patient care’ than ‘hospitalization.’

Since long, ‘OoP expenditure’ on hospitalization was being considered as the most important reason for impoverishment. Probably, this is the reason why various governments in India, had launched various health schemes, covering hospitalization expenses of a large section of the poor population in the country. The most recent one being – Ayushman Bharat-National Health Protection Scheme (AB-NHPS), often termed as ‘Modicare’, launched in September 25, 2018.

That total ‘OoP expenses’ are more on ‘out-patient care’ than ‘hospitalization’ was emphasized even in the 2016 research article titled, ‘Out-of-Pocket Spending on Out-Patient Care in India: Assessment and Options Based on Results from a District Level Survey,’ published online by PLoS One on November 18, 2016.

Highlighting that ‘OoP spending’ at ‘Out-Patient Departments (OPD)’ or in clinics by households is relatively less analyzed compared to hospitalization expenses in India, the results indicate:

• Economically vulnerable population spend more on OPD as a proportion of per capita consumption expenditure.

• ‘Out-patient care’ remains overwhelmingly private and switches of providers -while not very prevalent – is mostly towards private providers.

• High quality and affordable public providers tend to lower OPD spending significantly.

• Improvement in the overall quality and accessibility of government OPD facilities still remains an important tool that should be considered in the context of financial protection.

Let me now cite the second example – analyzing the 60th national morbidity and healthcare survey of the National Sample Survey Organization (NSSO), the study found, ‘outpatient care is more impoverishing than inpatient care in urban and rural areas alike.’

Expert committee’s recommendations for focus on ‘primary care’ went unheeded:

That the government focus on public health care should be on PHC, along with prevention and early management of health problems, was recommended by ‘The High-Level Expert Group Report on Universal Health Coverage, for India.’ This committee was instituted by the then ‘Planning Commission’ of the country on November 2011. The report also suggested, such measures would help reduce the need of secondary and tertiary care, significantly. But not much attention seems to have been paid even on these critical recommendations.

Conclusion:

Going by what Indian government says, I believe, its ultimate goal is providing access to affordable Universal Health Care (UHC), for all. That’s indeed commendable. But as various research papers clearly indicates, the country will first ‘need to invest in a ‘primary-care-centered’ health delivery system, if universal access to health care is to be realized, ultimately.

From this perspective, Ayushman Bharat – National Health Protection Scheme (AB-NHPS) may be a good initiative. But it does not seem to merit being the primary focus area of the government in public health care. And, not more than establishing high quality and robust ‘primary health care’ infrastructure, across the country, for all. Nor will AB-NHPS be able to address higher average of out-of-pocket ‘outpatient expenses’ of those people who need help in this area, the most.

Considering the critical public health care issue in India holistically, I reckon, for providing affordable access to health care for all, the top most priority of the Government should be to invest first where the mouth is – to create affordable primary healthcare infrastructure of a decent quality, with easy access for all.

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.