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:

1. out-of-pocket expenditure (OOPE)
2. catastrophic health expenditure
3. health payment-induced poverty

• 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:

1. adoption of standard clinical guidelines for diagnostic tests
2. treatments suitable for different disorders
3. setting and monitoring of cost and quality standards
4. measuring health outcomes and cost-effectiveness

• 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