India’s journey towards Universal Health Coverage (UHC) is gaining special attention since the Modi Government announced the country’s largest health care programme ever, named ‘Ayushman Bharat’ on 1st Feb, 2018 – just a year before the general elections scheduled in 2019. By way of example, Richard Horton discusses in this week’s Lancet Offline Comment how health will likely be a key issue in India’s 2019 general elections, quoting Modi as the first Prime Minister of India “to prioritize Universal Health Coverage as part of his political platform”.
The Ayushman Bharat (AB) Programme (which means “blessed India” in literal terms or “healthy India” in the context of health) rests on the twin pillars of the National Health Protection Mission (NHPM – the secondary & tertiary care social health insurance programme) and the establishment of 150,000 additional Health and Wellness Centres (HWCs- an updated version of primary health centres that will include a focus on wellness as well). In his Independence Day speech, Modi called the health protection scheme “Pradhan Mantri Jan Aarogya Abhiyaan” (PMJAA – meaning the Prime Minister People’s Health Mission). The programme has had quite a multi-monicker journey since its first announcement in Feb, 2018. Its name has been changed several times, all in the quest to find a Hindi name that would be acceptable to its target beneficiaries: from Modicare to National Health Protection Mission (NHPM) to Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM, meaning Prime Minister National Health Protection Mission), and now Pradhan Mantri Jan Aarogya Abhiyaan (PMJAA). PMRSSM was interestingly dropped for the presence of the letters “RSS” (Rashtriya Swayasevak Sangh- meaning National Volunteer Organization) in the name, RSS being the Indian right-wing, Hindu-nationalist voluntary organization. For the time being, though, Modicare and NHPM are the names used most frequently.
“Successor” of RSBY & some lessons from my PhD
Maybe good to know for you: I studied the implementation of Rashtriya Swasthya Bima Yojana (RSBY) in one of the western states of India for my PhD thesis. Using a theory-based evaluation, I identified the accountability mechanisms available in the programme design of enrolment and tried to understand how they functioned on the ground. Based on my 8-9 months of extensive field experience interacting with multiple stakeholders from all levels (public as well as private; national, state, district as well as local), I found that most of these mechanisms largely played a symbolic role. Hence, I have some serious concerns about the design and implementation of this newly announced AB-NHPM, as in many ways, it’s the successor of RSBY. Let me explain a bit more in detail below, after elaborating how NHPM differs from RSBY.
The National Health Protection Mission (NHPM) aims to provide free access to secondary and tertiary care to over 100 million households for a coverage of up to INR 5 lakhs (~7000 USD) annually, without any limit in terms of family size and age of the household members. RSBY, NHPM’s predecessor introduced in 2008, provided a financial coverage of INR 30000 (~500 USD) for a family of up to 5, to ~36.33 million households (against the target of 60 mn households). While the target population for RSBY was primarily the Below Poverty Line (BPL) population (based on the 2001 Census in a majority of the implementing states) along with a handful of unorganized sector categories, NHPM has improved upon this, by considering the Socio-Economic Caste Census, 2011 to identify its target beneficiaries. Still, a lag of 7 years will result in the exclusion of some eligible beneficiaries.
Enrolment (mandatory in RSBY) has been eliminated and replaced by the beneficiary identification process for AB-NHPM at the point of contact for healthcare i.e. healthcare facilities. Elimination of the first point of contact with the beneficiaries via enrolment in NHPM, makes the role of Information, Education and Communication (IEC) activities even more critical, as the beneficiaries need to know about their eligibility for the programme, programme features and benefits and ways to access it. Do not assume that the current mass media coverage on Modicare will inform the beneficiaries of all these details.
Similar to RSBY, NHPM aims to provide cashless, paperless transactions to its target beneficiaries with portability features, i.e. beneficiaries can get the treatment through any empaneled public or private hospital across the country. Evidence from RSBY implementation pointed to difficulties in settling inter-insurance claim settlements (in terms of delays and rejections). Also, like in RSBY, the new scheme will cover all pre-existing illnesses, pre-hospitalization, post-hospitalization, and transportation expenses, though the literature on RSBY reports beneficiaries who received treatment under RSBY incurred OOP expenditures particularly on medicines and diagnostics. The National Health Agency (NHA) and State Health Agencies (SHAs) – the agencies established at central and state levels respectively to manage and monitor the implementation of the programme, will have to ensure that the implementation of NHPM improves upon the mistakes identified in the implementation of RSBY, and make evidence-informed decisions.
Findings of my Ph.D. thesis also highlighted other critical issues in the design and implementation of the RSBY, more in particular the involvement of private actors at multiple levels (Insurance companies, Third Party Administrators, Smart Card Service Providers, and hospitals); their varying power relations with different levels of the government machinery, lack of clarity on specific roles and responsibilities of each of these implementing actors, often leading to poor communication and weak co-ordination amongst them while working on the ground, and all this coupled with weak accountability mechanisms. It is clear that many of these concerns will need to be addressed if implementation of NHPM is to be effective on the ground.
Apprehensions on the involvement of the private sector, and regulatory and monitoring elements in the design of NHPM make the findings of my thesis even more pertinent. In the absence of adequate accountability mechanisms, challenges like overutilization of health care services through over-prescription of diagnostics and treatment, converting outpatient into inpatient care, selectively choosing profitable cases or hospitals charging for cashless procedures are quite foreseeable, having been highlighted several times in the implementation literature of RSBY.
Nevertheless, ‘Modicare’ is seen as a significant step towards achieving the twin targets of SDG 3.8 of reducing the financial burden and increasing population coverage. India’s Health Minister, JP Nadda claims that ‘NHPM is going to be one of the world’s largest social health insurance programmes due to its sheer numbers and this scheme shall be a game changer for the Indian Healthcare’. Along with its preventive arm of establishing 150,000 HWCs aiming to provide comprehensive primary health care, AB can also be seen as improving on the third element (the other two being financial coverage and population coverage) of the “UHC cube”, i.e. improving access to a wider range of healthcare services. As NHPM gets the bulk of the attention, it is feared, however, that the HWCs might not receive their due resources.
In addition, while the focus is largely on increasing service coverage to ~40% of the country’s population, another potential challenge the scheme will face is the quality of services delivered. A Lancet article published coinciding with the launch of The Lancet Global Health Commission on High Quality Health Systems in the SDG era reported that 2.4 mn people in India yearly die due to treatable conditions, out of which 1.6 mn (~66%) die due to poor quality of health care, and the rest due to non-utilization of health care. While ‘Modicare’ would potentially increase the utilization of health care services in India, it should also at the same time focus on ensuring (and improving) the quality of health care services delivered through its empaneled hospitals and HWCs.
Around 6000 private hospitals are expected to join NHPM, but not all would be accredited by the National Accreditation Board for Hospitals and Healthcare providers (NABH), an accreditation board established by the Quality Council of India (QCI) to ensure quality standards in the delivery of healthcare. Only 540 hospitals across the country have NABH accreditation currently and not all of them may join NHPM. Given the incentive of 15% higher rates for approved treatments to NABH accredited hospitals and 10% higher rates to entry-level NABH hospitals, a rise can be expected (not sufficient, though) in the accreditation of hospitals as NHPM implementation takes off. With respect to the HWCs, other than the inauguration news of these centres in different parts of the country, there’s not much information on the availability and utilization of resources in terms of staff, medicines, medical equipments etc. and more importantly on how the quality of services delivery in these centres will be monitored. By the way, focusing on quality would also need integration with other social determinants of health like clean drinking water, hygienic toilets, nutritious food etc. as well as appropriate handling of bio-medical waste, especially in the hospitals, to prevent any hospital-acquired infections (but also in their homes).
Current picture & hope for a good start of Modicare
With the soft launch of NHPM by Modi on Independence Day, we now have 30 states and union territories on board (with Tamil Nadu being the latest to join). 21 out of the 30 states who agreed to be a part of NHPM are opting for the “trust model” (where the state establishes a trust and handles the entire implementation of the programme) as opposed to the “Insurance model” (where the state contracts out the insurance services to the insurance companies). With changes in the implementation design model, it won’t be easy to avoid state capacity deficits and other issues of alignment of central and state level schemes with respect to population coverage, financial coverage as well as service coverage, that much is clear. It would also be important for the states to have clearly defined roles and responsibilities for each of the implementing actors to avoid any ambiguities at the time of roll out.
On a more positive note, pilots have now started in more than half of the agreed states and the first claim under NHPM has already been raised from a public hospital in Haryana for a newborn baby girl.
If Modicare is implemented effectively, the landscape of Indian Healthcare will indeed substantially be transformed in the coming years. With the official launch date of 25th September quite near, the NHA and SHAs will have to gear up their preparation for the implementation of NHPM. As hiccups can be expected and are only normal if such a huge scheme is to be rolled out, hopefully, these agencies will turn out to be ‘learning systems’, being quick and responsive in addressing these initial hiccups.
Last but not least, I also hope that Modicare doesn’t get caught in a similar destructive polarization process as is the case in the US for Obamacare. Indians need UHC, more than ever.