Ayushman Bharat programme - II

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What is the issue?

The recent budget announced the Ayushman Bharat programme.
It is imperative at this juncture to look into the various facets of the programme to assess its potential in health care services.

What are the shortfalls?

Rashtriya Swasthya Bima Yojana (RSBY) was a precursor of the National Health Protection Scheme (NHPS).
It provided limited coverage of Rs.30,000, usually for secondary care.
The NHPS addresses the concerns in RSBY relating to:

NHPS has sharply raised the health care coverage.
However, the shortfall of not covering outpatient care in RSBY continues in NHPS as well.
Notably, outpatient care accounts for the largest fraction of OOPE.
They include medical procedures, surgeries, therapies, classes, diagnostic tests, etc without the need for patient's overnight stay.
The NHPS also remains disconnected from primary health care services.

The transformation of sub-centres to health and wellness centres under the NHPS is welcome.
However, the reduced allocation for the existing National Health Mission and sidelining of its urban component raises concerns.
It signals a neglect of primary health care.

Why is primary health care so significant?

Primary health services need to be strong enough to reduce the need for advanced care.
Less attention for primary care could lead to an overloaded NHPS.
This in turn could disproportionately drain resources from the health budget.
This could lead to further neglect of primary care and public hospitals.
Notably, even now these are not adequately equipped to compete with corporate hospitals in the strategic purchasing arena.
This shortfall in health care policy is potential of ruining the public sector as a health care provider.

What are the financial implications?

Unlike a private insurance where an individual/employer pays the premium, in NHPS the government pays most of the money.
A large number of people subscribe to an insurance scheme.
However, only a small fraction of them will be hospitalised in any given year.
Given these, the NHPS is expected to be a financially viable option.
However, it will need more than the presently allocated Rs.2,000 crore.
Around Rs.5,000-6,000 crore is required to sustain it in the first year and Rs.10,000-12,000 crore annually as it scales up.
It will draw additional resources from the Health and Education Cess.
It will also depend on funding from States to boost the Central allocation.

What will the role of States be?

The State governments have the main responsibility of health service delivery.
The NHPS needs a buy-in from the States, which have to contribute 40% of the funding.
The National Health Policy (NHP) asks the States to raise their allocation for health to over 8% of the total State budget by 2020.
The NHP proposes the centre to raise public health expenditure to 2.5% of GDP by 2025.
The Central Budget has not signalled a movement towards this goal.
Given this, the states taking actions on the NHP goal is highly uncertain.
Notably, the goal requires many of the States to nearly double their health spending.
Even with the low cost coverage of the RSBY, several States opted out.
Some decided to fund their own State-specific health insurance programmes, with distinctive political branding.

Given this, the states merging their programmes with the NHPS seems doubtful.
The choice of whether to administer NHPS through a trust or an insurance company will be left to individual States.

What lies ahead?

Primary health services and public hospitals should be proactively strengthened.
Capacity building - The NHPS will pay for the hospitalisation costs of its beneficiaries.
This will be done through ‘strategic purchasing’.
It refers to allocation of pooled financial resources to public and private hospitals who are healthcare providers.
This calls for a well-defined list of conditions including:

Both Central and State health agencies or their intermediaries will have to develop their respective capacities.
This is essential for competent purchasing of services from a diverse group of providers.
Otherwise, there is a possibility for the hospitals to undertake unnecessary tests and treatments to tap the generous coverage.

Federal - In a federal polity, an all-India alignment around the NHPS requires a high level of cooperative federalism.
This is a prerequisite to make the scheme viable and ensure portability of coverage as people cross State borders.

Source: The Hindu