“Health care is the cornerstone of the socialist state. It is the crown jewel of the welfare state”—quoted by Monica Crowley holds true in all aspects. A country’s actual wealth lies in its people. United Nations Development Programme annual report of 2018 states that the basic and fundamental aspect of governance is “state of health care in any country”.
Health care is a fundamental right, but it is not fundamentally right in India. The Supreme Court has held health care to be a fundamental right under Article 21 of the Constitution. However, historical public spending of just over a percent of GDP on health care has ensured that the country’s health care need has remained underserved and left for the private sector to service. The fundamental aspect of health care—primary health care—is in a shambles. There is only one primary health care centre (often manned by one doctor) for more than 51,000 people in the country. The World Bank report states that 90% of all health needs can be met at the primary health-care level.
Primary health centres are the backbone of the rural health-care system. By 1991, India had about 22,400 primary health centres, 11,200 hospitals, and 27,400 dispensaries. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside. Primary health centres and sub-centres rely on trained paramedics to meet most of their needs.
The main problems affecting the success of the primary health centres are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas and on the outskirts of the town. In addition, disintegration of health services with family planning programmes often causes the local population to perceive the primary health centres as hostile to their traditional preference for large families, or beliefs carried from the time immemorial. Therefore, primary health centres often play an adversarial role in local efforts to implement national health policies. “Success starts from base” a very practical quote which we all know and even implements. The same happens in health care also. If the basic tier is not strong how can we expect the apex to be strong.
India is presently in a state of health transition. Infectious diseases such as tuberculosis, as well as malaria, dengue, H1N1 pandemic influenza and antimicrobial resistance remain a continued threat to health and economic security over the past six decades. At the same time, the country is having to confront the emerging problem of chronic non-communicable diseases such as cardiovascular diseases, diabetes, cancer which are now the leading cause of mortality rate in our country.
This epidemiological transition is being fuelled by social and economic determinants of health sector,
as well as by demographic changes such as an ageing population, by environmental factors such as climate change and environmental change, and by factors such as globalisation, urbanisation and changing lifestyles.
To cater to the primary health-care system, our honourable Prime Minister has launched a flagship scheme “Ayushman Bharat”.
To address these challenges, Finance Minister Mr. Arun Jaitley on February 1, 2018 unveiled the world’s largest government-funded health programme termed as “National Health Protection Scheme”(NHPS), covering 10 crore families or approximately 50 crore people, with Rs. 5 lakh insurance cover per family per year. This scheme is for secondary and tertiary health care, mainly for hospital care.
This flagship scheme is most likely to benefit more than 37% of the population, meaning that nearly all the poor and vulnerable families will be covered. The government will require Rs. 12,000 crore for its implementation, with cost shared on a 60:40 basis between Central and State governments.
Mr. Jaitley further announced setting up or converting some 1,50,000 subcentres in the country into so-called “health & wellness” centres which will offer a set of services including maternal and child health services at the primary level, mental health services, vaccinations against selected communicable diseases, and screening for hypertension, diabetes and some cancers. The sub-centres which at present cater to a population of about 5,000 people each and are manned by two paramedical staff.
The Ayushman Bharat programme is apparently driven by two main aims: 1) to strengthen primary health care which has been lacking in the country for the past six decades and 2) to offer financial protection from catastrophic expenditure, often encountered once a family member is sick and needs long-term health care.
The scheme, if implemented properly, could be a game changer by enhancing access to health care including early detection and treatment services by a large section of society which otherwise cannot afford them and in lieu falls victim. The identification of beneficiaries can be done by linking with Aadhaar and similarly following up for services received and health outcomes achieved, thereby helping to monitor and evaluate the impact of the programme.
Ultimately, NHPS can help country move towards universal health coverage and equitable access to health care which is one of the UN Sustainable Development Goals or SDGs. This new scheme builds on the already existing Rashtriya Swasthya Bima Yojana or RSBY—a health insurance scheme for the below poverty line families, with entitlement of up to Rs. 30,000 per annum for diseases requiring hospitalisation. However, given that States are expected to agree for 40% share under the NHPS and that health being a State subject, State ownership and commitment will be critical for the success of the programme.
The Finance Minister has made a budget allocation of Rs. 52,800 crore for the Health Ministry, up from Rs. 47,352 crore during the previous year signifying an increase of 11%, yet as percentage of the GDP, it is still among the lowest in the world. In addition, the government plans increase the levy of health cess from 3 to 4%. According to Health Minister Mr. J.P. Nadda, Rs. 2000 crore have been allocated as of now.
It is clear that the NHPS scheme, which primarily offers support for clinical services such as hospitalisation, is unlikely to help fix the broken public health system in the country. The most critical issue remains the limited and uneven distribution of human resources at various levels of health services, with up to 40 percent of health worker posts lying vacant in some States. Most primary health care centres suffer from perennial shortage of doctors and even district hospitals are without specialists.
Without addressing the human resource situation, public sector health care will remain of poor quality and largely unacceptable, forcing patients to go to the private sector. Therefore, it seems as if NHPS is likely to benefit private parties more than government health services. This will ultimately be unsustainable and for even detrimental to the poor for whom the scheme is intended. To maximise benefits, it may be wise to establish a link among various health initiatives announced in the budget and also with related programmes such as the National Health Mission. Clarity is also needed on what services will be provided by government health facilities and for which conditions patients will have to use private parties and what mechanisms are being thought of. There is a need for uniform pricing systems for various health interventions, including diagnostics and medicines, and making them transparent by displaying them in hospital premises.
Moreover, a continuum of care system also needs to be established by linking institutions or hospitals, with health centres and the community. Community engagement is thus crucial in planning and implementation of the programme and in ensuring that the health and wellness centres and the primary health centres are responsive to the needs of the community.
Finally, the scheme is innovative and path-breaking in the history of public health in India, which may have a transformative impact if implemented in an effective and coordinated manner. The enduring interest and level of discussion in the media do reflect the wider realisation in the country that only healthy people can build a strong and prosperous nation.