It’s all in the design: Ayushman Bharat can be transformational if governance of public healthcare is altered

by Arvind Panagariya

March 7, 2018

The Times of India

Other than the Swachh Bharat Mission, ‘Ayushman Bharat’ is potentially the most far-reaching social programme initiated by Prime Minister Narendra Modi. For the first time, the programme gives vulnerable families hope that they will be able to escape financial ruin when faced with illnesses requiring hospitalisation.

Though the media has focussed disproportionately on the National Health Protection Scheme (NHPS) aimed at covering 100 million households for secondary and tertiary care, Ayushman Bharat also includes a component that proposes to strengthen primary healthcare. This latter component would establish 1,50,000 Wellness Centres.

To ensure success, it is important that enough thought goes into designing the two schemes. More than five decades worth of experience with the provision of primary, secondary and tertiary healthcare by the government have been deeply disappointing.

Illustration: Uday Deb

Those in charge of shaping the schemes must study the reasons for this failure and consult the best experts in health economics and management. This is a technical field in which the design of schemes is just as important as implementation. Failure to give technocrats sufficient voice risks reproducing the same failures we have witnessed over the last half century.

Consider first primary healthcare via our existing public healthcare system. Since at least the early 1960s, we have been investing in a massive network of sub centres (SCs), primary health centres (PHCs) and community health centres (CHCs) in rural India. SCs serve as the first point of contact between people and public health system. They provide public health services such as immunisation, curative care for minor aliments and maternal and child health and nutrition. They employ one male and one female worker with the latter being auxiliary nurse and midwife.

PHCs serve as referral units for six SCs and have a qualified doctor and four to six beds. CHCs serve as referral units for four PHCs. They have four doctors covering different specialties, 21 paramedical and other staff, 30 beds, an operation theatre and X-ray room.

Population norms per centre for the plains are 5,000 for SCs, 30,000 for PHCs and 1,20,000 for CHCs. With 1,56,000 SCs, 25,650 PHCs and 5,624 CHCs as per the Rural Health Statistics, 2017, we are currently within striking distance of these norms.

Admittedly, resource shortage has meant that SCs, PHCs and CHCs have had less than adequate infrastructure and personnel. But even making generous allowance for these deficiencies, service delivery has been disappointing. In 2014-15, a mere 28% of those needing outpatient care came to these facilities. A hefty 72% of patients went to private providers.

Considering that the private providers are predominantly unqualified individuals, often having no more than high school education and no formal medical education, such disproportionate reliance on them is indicative of a serious failure at SCs and PHCs. More than 50 years of investment have not resulted in rural households placing much trust in the SCs and PHCs.

Therefore, we need to be sure that the proposed Wellness Centres are designed to succeed where SCs and PHCs have largely not succeeded. Minor adjustments to SCs to turn them into Wellness Centres will not work.

Superior outcomes would require a fundamental change in governance whereby performers are rewarded and non-performers are punished. The story on secondary and tertiary care is not especially different. In 2014-15, private hospitals treated 58% of in-patient cases in rural areas. Even among the poorest 20% rural households, 42.5% of the patients went to private hospitals for in-patient treatment.

For the poorest of the poor to seek private hospital care speaks volumes for their lack of confidence in the public healthcare system. Studies by experts do not give high marks to existing insurance schemes either. For instance, a 2017 study of the Rashtriya Swasthya Bima Yojana (RSBY), published in the journal Social Science and Medicine, concludes, “Overall, the results [of our study] suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households.”

As officials design the Wellness Centres and NHPS, they must keep in mind this historical failure in the delivery of healthcare by public sector. Without a major change to the governance model, the risk that Wellness Centres would reproduce the failures of SCs and PHCs is high.

Design and implementation challenges facing NHPS are even greater. Hospitals will have an inherent interest in pushing patients towards more expensive procedures or towards procedures not even required. Any lack of clarity in delineating the included and excluded procedures will become a source of abuse.

The state nodal agencies will have to have sufficient resources and technical and administrative capability to monitor and check such abuse. Also, while the idea of ‘One Nation, One Scheme’ is enticing, we should not lose sight of the fact that we are a diverse nation. While the scheme can be one, it has to have sufficient flexibility built into it so that local administrations can adjust it as per local needs.

The current approach of National Health Mission – whereby states must pre-commit to expenditure allocations across 2,000 budget lines with no real flexibility to subsequently move expenditures between different line items – will render NHPS ineffective.

DISCLAIMER : Views expressed above are the author's own.