At a glance, the Ayushman Bharat scheme of the central government would seem like wild fantasy. The scheme proposes to employ healthcare insurance to cover the costs of secondary and tertiary care (meaning hospitalization) for 10.74 crore of India’s poorest and most vulnerable citizens on the basis of the Socio Economic Caste Census (SECC). The flagship scheme of the Modi government, often dubbed, ‘Modicare’, on the lines of America’s ‘Obamacare’, is a measure deemed to please the public at large. Ever since its announcement, in the 2018 Budget speech, circles have been rife with debate on how practical it is to implement a scheme that could potentially cost Rs 5 lakh per person and benefit 53.7 crore out of India’s 121 crore citizenry, or, roughly about 44 percent of the country’s population.

India’s Poor Public Healthcare Spending

At about 1.3% of the national income, India’s public healthcare spending, between 2008 and 2015, has virtually remained stagnant. To understand the impact of this number, the government expenditure on health per capita of its people stands at Rs 1,112 a year, or Rs 3 per person per day. In comparison, the average claim amount per insured person, according to the Insurance Regulatory and Development Authority in 2009-10, was Rs 1,34,990 for a single major disease. Clearly, such massive out-of-pocket expenses have the propensity to throw personal finances out of gear and into the thresholds of poverty. Hence, the catastrophic effects of medical costs in case of a major illness have to be addressed directly. Because inflation in healthcare expenses has been known to increase faster than general inflation, the problem is likely to get worse in the future.

Lack of Qualified Doctors and Healthcare Penetration

A 2016 WHO study, titled, ‘The Health Workforce in India’, reports the doctor-density ratio in India at 8 per 10,000 people. If only qualified health professionals were considered, this number would fall to less than half of what it is now. The United Nation’s Sustainable Development Goals propose universal healthcare access as a fundamental objective to guide national policies and healthcare frameworks. To achieve such access, merely increasing the number of primary and secondary healthcare centers is not enough. Access should also be equitable. This means that everyone is entitled to the same quality of healthcare facilities as are available at the best of places. However, lack of human resources, proper diagnostic equipment and standard protocols can severely mar the impact of any national scheme aiming to push universal healthcare access.

Infrastructure creation and Quantity of Healthcare Centers should go hand-in-hand

The NHPS, scheduled to be launched formally on August 15 this year, also contains a component that envisages the creation of 1,50,000 new health and wellness centers across the country by 2022. As of June 2018, the number of primary health centers (PHCs) increased to 32,743 and number of sub centers reached 167,732in India. However, the quality of healthcare services to be provided at government run facilities remains a challenge owing to lack of timely funding and sources of maintenance. Notwithstanding the above, incorporation of technology such as telemedicine at costs that bear proportion to that afforded by the rural public can ensure greater success to the outcomes from this program.

With rising teledensity and mobile connectivity, internet access is available at very remote places today. Doctors must be encouraged to spend some of their time providing consultations to an exclusively rural clientele over the online medium. Grassroots healthcare workers may be given smartphones and be trained to access medical professionals for expert views and reviews. They may then eventually coach people in the villages to use these devices and converse with medical experts themselves. Facilities should be made available to transport blood or other tissue samples to the nearest clinical laboratory for determining the course of therapy to be administered. Without supporting infrastructure such as roads, internet connectivity and a steady supply of electricity, the NHPS would not be able to deliver its objectives effectively.

Funding Challenges to the NHPS

One of the major criticisms of the NHPS is that it does not provide a cogent mechanism to fund the potentially huge expenses that implementation is likely to incur. At present, funding sources are the Central Government, the States and the individual. If one assumes that there are 5 people in a family on an average, then the requisite cost to the exchequer could run into trillions of rupees. But, insurance does not work that way. Risk insurance assumes that everyone is not likely to fall sick in the same year. That way, pooled funds from other subscribers can be used to pay for expenses incurred by those who do fall sick.

Apart from using a limited corpus of money to fund healthcare expenses for a few, insurance also provides the advantage of hedging against inflation. Pre-paid expenses mean that you will not be charged for any increase in prices over and above the value advertised, at any later stage.

People must also be educated to get their ailments diagnosed at the appropriate stage and this should not be a prerogative of the rich. The practice of family doctors must be promoted at the village level even if consultations are by remote telephony.

Until people are affected and touched by an outreach of the NHPS, it is not likely that the Modi government will be able to garner praise or credit for its impact. And the way to gain credible impact is by factoring in all the challenges the scheme is likely to face when it is being implemented. Till then, this ambitious scheme is likely to remain a paper ‘tiger’.