India’s tectonic shift towards UHC | Dr Rana Mehta

The world’s largest health insurance scheme finally saw the light of day with the Prime Minister’s announcement on August 15, 2018. The scheme promises a health cover of INR 500,000 per family (for around 10 crore households). In addition, the scheme envisages setting up of  more than 150,000 health and wellness centres throughout the country to provide primary and preventive care. The scheme marks the transition of the Indian government’s role in healthcare—from a provider to a payer. It also lays the foundation to fix a healthcare system characterised by supply side financing, high fragmentation, non-standardisation and questionable outcome.

Although every developed country offers some sort of government-sponsored health insurance benefits to its citizens, the Pradhan Mantri Jan Arogya Yojana (PMJAY) is different in multiple respects both from a coverage and roll-out perspective. While the amount insured is significant, the scheme itself is non-contributory (tax funded) with no underwriting activity involved. A standard premium will be given per family, irrespective of pre-existing illnesses or size of the family household. There is no beneficiary identification process and beneficiaries will be enrolled on the basis of Socio Economic Caste Census 2011. Furthermore, the scheme can be managed both by trust-based model and insurance model. However, with a majority of states opting for a trust-based model, a scheme of this magnitude may miss the rigour of fraud prevention and medical claim analytics processes built in private commercial insurance business.

Besides improving financial affordability, the scheme also addresses other significant challenges in Indian healthcare. The scheme advocates standardisation, with incorporation of package rates, standard treatment guidelines, common medical data dictionary and standard operating protocols for beneficiary identification and transaction management. With increased rates offered for accredited hospitals, NABH accreditation will become more ubiquitous. Portability and rapid transaction processes will enforce increased levels of technology adoption in the form of maintenance of medical records, disease coding, claim processing and interaction with other stakeholders. With health and wellness centres, preventive care is given the desired push. Furthermore, the scheme will generate magnitude of data both from healthcare providers and patients, which can be used to create data registries such as National Health Resource Repository (NHRR) and Registry of Hospitals in Network of Insurance (ROHINI). This data can be used to assess epidemiological and treatment patterns, and design and implement better suited health policies.

With a potential to create more than 10,000 jobs immediately, effective implantation of NHPM will also require a new cadre of skilled work force (such as medical coders) and reskilling of existing workforce (such as nurses and lab technicians). Moreover, setting up of new care delivery institutions in Tier 2 and 3 cities will enforce redistribution of healthcare workforce, which is currently concentrated primarily in metros and tier 1 cities.

Considering the size and magnitude of this scheme, an effective implementation roadmap is imperative for its success. Concerns around low package rates, infrastructure requirements, fraud and leakage management, budgetary and capital requirements etc. needs to be properly addressed. Furthermore, an effective information and communication roadmap needs to be developed to ensure high utilisation of this scheme and help achieve its intended objectives.

PM JAY allows India a historical chance to put in building blocks, which will determine the healthcare of its citizens in the coming decade. Considering the scale and likely impact of PM JAY, it is imperative that the scheme incorporates learning from the other previous schemes implemented in India and in other countries. A successful implementation will ensure that it is allowed to evolve and help achieve the Government’s vision of universal healthcare.

(With inputs from Dr Ashwani Aggarwal – Principal Consultant – Healthcare, PwC. Views expressed are personal)

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