Highlights

• Universal health coverage is getting prioritised as a part of political reform with the launch of two pillars of the Pradhan Mantri Jan Arogya Yojana (PMJAY): Ayushman Bharat (AB), where 1.5 lakh health sub-centres are being converted into health and wellness centres; and the National Health Protection Mission (NHPM), which aims to provide health cover of Rs.5 lakh per family, per annum, reaching out to 500 million people.
• The “best health care at the lowest possible cost” should be: inclusive; make health-care providers accountable for cost and quality; achieve a reduction in disease burden, and eliminate catastrophic health expenditures for the consumer.
• It could come about, however, if accompanied by the nuts and bolts of good governance that will support solutions and systems to achieve these objectives.

Align entitlement to income

• In the matter of inclusion, over 15 years ago, the Vajpayee government commissioned the Institute of Health Systems (IHS), Hyderabad to develop a ‘family welfare linked health insurance policy’ which delivered a broad-based Family Health Protection Plan (FHPP), open to all individuals.
• The fact is that any discourse on universal health care in India gets stymied by the sheer size and ambivalence of the numbers involved.
• This 2003 solution of the Vajpayee-era recommended, inter alia, that good governance lies in aligning the income lines for health and housing.
• In that event, the income lines for housing (updated from time to time), could be simultaneously applicable for health entitlement.
• The government could then proceed, as per capacity, to scale the health premium subsidy in line with housing categories — economically weaker sections (entitled to 75-90%), lower income (entitled to 50%), and middle income groups (entitled to 20%).

Build in accountability

• The NHPM is pushing for hospitalisation at secondary- and tertiary-level private hospitals, while disregarding the need for eligible households to first access primary care, prior to becoming ‘a case for acute care’.
• Without the stepping stone of primary health care, direct hospitalisation is a high-cost solution.
• Public sector health capacities are constrained at all levels where forward movement is feasible only through partnerships and coalitions with private sector providers.
• These partnerships are credible only if made accountable.
• The National Health Policy 2017 proposed “strategic purchasing” of services from secondary and tertiary hospitals for a fee.
• Clearly, we need to contract-in services of those health-care providers (public and private) who are assessed as competent to provide all care for all the medical conditions specified; who will accept and abide by standard treatment protocols and guidelines notified, as this will rule out potential for induced care/unnecessary treatment; and who will accept the AB-NHPM financial compensation package (with fixed fees per episode, and not per visit).
• The credo for participating private providers should be “mission, not margin”.
• Health-care providers (public/private) should be accredited without any upper limit on the number of service providers in a given district.
• The annual premium for each beneficiary would be paid to those service providers, for up to one year only (renewable), as selected by beneficiaries.
• The resultant competition would enhance quality and keep costs in check.
• Upgrading district hospitals to government medical colleges and teaching hospitals will enhance capacities at the district level.
• Service providers will become accountable for cost and quality if they are bound to the nuts and bolts of good governance outlined above.

Transform primary care

• Third, elimination of catastrophic health expenditures for the consumer can come about only if there is sustained effort to modernise and transform the primary care space.
• Bring together all relevant inter-sectoral action linking health and development so as to universalise the availability of clean drinking water, sanitation, garbage disposal, waste management, food security, nutrition and vector control.
• The Swachh Bharat programme must be incorporated in the PMJAY.
• These steps put together will reduce the disease burden.
• At the 1.5 lakh ‘health and wellness clinics’ (earlier, health sub-centres), register households to provide them access to district-specific, evidence-based, integrated packages of community, primary preventive and promotive health care.
• The health and wellness clinics must connect with early detection and treatment.
• The cornerstone of the Vajpayee-era FHPP was the primary medical clinic providing ambulatory primary care, out-patient consultation, clinical examination, curative services, and referrals.
• Robust delivery of preventive, clinical and diagnostic health-care services will result in early detection of cancers, diabetes and chronic conditions, mostly needing long-term treatment and home care.
• This will further minimise the demand for hospitalisation.
• Investment in primary care would very quickly reduce the overall cost of health care for the state and for the consumer.
• Technology and innovation are further reducing costs.
• As we integrate prevention, detection and treatment of ill-health, the PMJAY will win hearts if people receive a well-governed ‘Health for All’ scheme.

The Hindu