On the eve of August 15th, 28 states and UTs had already signed the MoU for Ayushman Bharat National Health Protection Mission (AB-NHPM). The National Health Protection Scheme (NHPS) has been credited as the world’s largest health insurance plan. It aims to provide a health insurance cover of up to INR 5 lakh annually to 10 crore families, which would in turn cover 40 per cent of country’s population. RSBY, the earlier predecessor of Ayushman Bharat was able to reach 3.6 crore families over a 10-year timeframe against a targeted coverage of six crore families, let’s say 60 per cent success rate in 10 years. Undoubtedly, the scheme is very well intentioned and fundamentally ambitious which is the need of the hour. However, there are few crucial pillars to make it successful infrastructure, workforce and a strong focus on overall quality.
Infrastructure creation and utilisation
India has around 1.6 million hospital beds and around 55,000 hospitals (excluding community health centres and primary health centres). While metros and tier-I towns have as high bed density as four beds per 1000 population, other towns lag far behind. The government needs to smartly build capacity starting with primary healthcare. Good primary care is essential for a healthy nation and in the same context AB also proposes setting up of 1.5 lakh health and wellness centres across the country. Addressing problems associated with supply logistics and spurious medication is another challenge. There could be an opportunity to tie up with players involved in last mile logistics to tackle some of these challenges.
One of the potential roadblocks could be participation from the private sector. There has been a lot of debate around procedure pricing across multiple platforms, most of it around viability of proposed pricing. Private healthcare providers are reluctant to enrol with NHPS at the current procedure pricing. However, healthcare providers need to build efficiencies rather than look at pricing in isolation. In states such as Rajasthan which has Bhamashah Swasthya Bima Yojana (BSBY), a state-run insurance scheme with prices comparable to Ayushman Bharat, healthcare providers have gradually built in efficiencies to make this successful and in turn also generate surplus. Another counterargument to the pricing paradox is reflected in the number of registered hospital projects in pipeline. Currently, there are ~500 registered hospital projects in pipeline with an overall documented investment of ~` 80,000 crore. In addition, quite a few international players are eyeing a large share in the Indian healthcare, IHH being one example. Increased state coverage would undoubtedly increase access to healthcare and hence hospitals would witness an increase in patient volumes. On the face of it, pricing does not seem to be a deterrent to the success of the scheme. The overall margin for hospital providers in India has historically been higher than some of their counterparts across the globe and this could partially explain why international providers eyeing the Indian market see the scheme as an opportunity. NHPS would, however, need to streamline the entire billing and collection cycle to enable hospitals manage their cash flows; currently this is a gap across most state-run health insurance schemes.
Bridging the workforce gap
Our country has around one million doctors. While states like Karnataka and Tamil Nadu have 1.5 doctors per 1000 population, states like Bihar and Assam have less than 0.5 doctors per 1000 population. Apart from physicians, contractual staff accounts for more than half of skilled workforce in the country. Creation of skilled manpower through training courses could increase resource efficiency for doctors. Healthcare Sector Skill Council (HSSC) has already taken the initiative to create a better skilled healthcare workforce. Certain practices such as midwifery which have been quite successful in other countries need planning and mass implementation. There are sporadic learnings from other countries as well. Ethiopia has a concept of health extension workers who are rural high school graduates undergoing one-year training before they are sent back to their native areas; the practice has led to reduction in child and maternal mortality by 32 per cent and 38 per cent respectively.
Delivering quality
In India, the average length of doctor consultation is little more than two minutes and features a single question – “What’s wrong with you?” Not surprisingly, research done by World Bank has shown that only 30 per cent of the consultations have resulted in correct diagnosis. While we have quality standards drafted by bodies such as NABH (National Accreditation Board for Hospitals), compliance is altogether a different subject. We need to create incentives around quality for empanelled hospitals. Undoubtedly this would entail a large-scale quality and patient experience audit beyond the existing conventional practices. Practices such as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) in the US need to be studied and could be suitably adapted to the Indian context.
Monitoring dashboards
Internationally, eight to ten percent of resources are wasted due to fraud and scheme abuse. Experts opine that Obamacare takes 40 per cent of resources for monitoring. It is important to create right monitoring dashboards for the success of the scheme starting from identification and verification of beneficiaries to hospital empanelment, diagnosis and treatment and claims vs complaint. At each stage, a robust monitoring would ensure large scale and long-term success of the scheme.
Spending in healthcare was earlier dubbed as social overhead but now economists at World Bank have documented evidences that this spending accelerates the growth of the nation. If implemented well, there are clear evidences of the impact NHPS would create in meeting the healthcare goals of the nation; some of them being increase in average life expectancy by five years, reduction of child deaths by ~ 50 million and many more. A participative and inclusive approach by government and non-government healthcare providers would be critical to success of the largest healthcare insurance plan across the world.
As Dr Indu Bhushan, CEO, AB puts it, “Constraint is not money but the capacity to spend the money effectively. We need to strengthen existing capacity. We need to put people in place, strengthen capacity of their hospitals, empanel more hospitals, select and train Ayushman Mitra, ensure monitoring systems to know how the money is being used.”
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