Have Modi-Jaitley missed a trick by ignoring primary healthcare in ambitious health insurance scheme?

The National Health Protection Scheme promises to deliver in healthcare what India severely lacks. But, experts are worried about its reliance on secondary and tertiary health facilities and the potential of misuse

The NITI Aayog is contemplating developing an IT platform to handle different aspects of this complex and monumental scheme, but how it meets the challenges envisaged by the healthcare industry will be the key to its success

Approximately 22 per cent, or one in every five, Indians are poor, says a report by the World Bank. According to the “Global Burden of Disease” study, published in The Lancet, India ranks 154th among 195 countries on the healthcare access and quality index. Put together this information, and we get an enormously high number of people who are pushed into penury every year because of high out-of-pocket medical expenses.

Finance minister Arun Jaitley proposed the National Health Protection Scheme (NHPS) in the 2018 Budget. Analysts feel that this is Prime Minister Narendra Modi’s answer to the Manmohan Singh’s Mahatma Gandhi National Rural Employment Guarantee Scheme with an eye on the next General Election. The NHPS promises what India severely lacks – a health insurance for the bottom rung of the society. Aimed at providing a health cover up to Rs 5 lakh to nearly 10 crore families (approximately 50 crore people or nearly 40 per cent of the population) from the vulnerable and the deprived classes, the scheme could bring about a social as well as economic change of gigantic proportions if implemented successfully. Besides the obvious benefit of assisting the economically weaker sections in getting proper medical care, it will also boost the economy by cutting down on loss of person-hours. However, it is not as simple as just making an announcement. SME Futures spoke to experts from the healthcare industry who cautioned against the possibility of misuse as well as gaps that need to be plugged in this scheme.

Success of NHPS depends on cooperative federalism: Dr O P Yadava

“One good thing about this scheme is that there are no exclusions and all pre-existing conditions will be covered from the very first year of the policy. Also, the benefits are portable across the length and the breadth of the country – indeed a right step in the direction of the utopian dream of universal health coverage and equitable distribution of health resources,” says Dr O P Yadava, CEO and chief cardiac surgeon, National Heart Institute, New Delhi. “Nearly 40 per cent of the population may benefit from this welfare scheme, which makes it probably the world’s largest such scheme,” he adds.

He agrees that not only would this scheme mean wider and deeper penetration of insurance in healthcare but also act as a corollary for other fields, like vehicle and home insurance. “This will give stability, both emotional and economic, to the vulnerable families and avoid disruptive upheavals, with cascading positive impact on banking industry too with fewer defaults. Improving health will translate into higher productivity and wealth, which bodes well for the banking sector,” Dr Yadava adds.

Calling for some caution to be exercised, he adds that though the Centre will fund the scheme, its success will depend on “cooperative federalism”, something which cannot be taken for granted, given that the governments in the state and at the Centre may not have the same affiliation. “It involves the states sharing the financial burden (40 per cent) by matching the grants by the Centre,” says Dr Yadava.

Dr OP Yadava, CEO and chief cardiac surgeon, National Heart Institute - SME Futures

“Exploitation sans meaningful regulation by predatory private sector is a lurking danger. In fact, the community at large must participate in governance and regulation for salutary results. The role of the media as a watchdog cannot be overemphasised,” he adds.

Exploitation by private players cannot be ruled out: Dr Hitendra Ahooja

Lauding the initiative, Dr Hitendra Ahooja, medical director of Ahooja Eye and Dental Institute, points out that most of the ailments prevailing in India are chronic, be they heart diseases, respiratory tract infections, asthma, tuberculosis, diarrhoea or others. These require regular outpatient consultations and hospitalisation is the only option. “When it comes to providing healthcare to 130 million households falling in the deprived category – which constitutes almost 50 per cent of the population – a properly executed NHPS with efficient measures can do justice to the underprivileged,” he avers.

His concern is exploitation by private clinics and corporate hospitals, which provide most of the healthcare in India. The solution is not to exclude the hospitals and clinics from the NHPS, but to keep a check on or monitor them and create right incentives for them, he suggests. “First and foremost, not all hospitals and clinics should be eligible for the NHPS. Quality standards should be set. Only those hospitals and clinics which are able to meet the quality standards should be allowed to serve the NHPS beneficiaries. Secondly, NHPS doctors should review medical records of beneficiaries thoroughly to make sure that the treatment required meets evidence-based guidelines,” says Dr Ahooja.

He is of the opinion that the scheme cannot meet the health needs of India by itself. Every person has to make some contribution to make it a success. “Corporate houses should be roped in through their corporate social responsibility activities for the infrastructure of primary, secondary and tertiary health centres and meet the acute shortage of human resources, like doctors, nurses and health workers. In due course of time, the NHPS will provide insurance to the poor, increasing lifespan through universal health coverage,” he says.

It must identify the serviceable population correctly: Dr Ruchi Dass

Raising more red flags is Dr Ruchi Dass, managing director of HealthCursor Consulting Group. “The NHPS scheme may look like good news to many. However, it will turn out to be no different than the Rashtriya Swasthya Bima Yojna (RSBY) and the other existing cashless public health insurance schemes if it is not able to identify the serviceable population, keep preventable diseases in check or cover even half of the out-of-pocket expenditure incurred on healthcare,” she says.

Dr Ruchi Dass, managing director of HealthCursor Consulting Group - SME Futures

There are many reasons to look forward to the impact of this scheme, Dr Dass says. It will increase public health expenditure in India from current 1.4 per cent of GDP (which is way below the international average of six per cent) to 2.5 per cent in next five years. She considers it a drawback that the scheme seeks to provide coverage for hospitalisation at the secondary and tertiary levels of healthcare at a time when most of the population in India still does not have access to basic primary healthcare. Healthcare expenditure in India is mostly on drugs/medicines and diagnostic tests; however, the mission is focussed more on pre- and post-hospitalisation charges, which in most cases is not necessary, she explains. Again, focus on prevention and early management of health problems is not defined clearly. “Support and vision to fund and deploy digital health technologies presents a huge opportunity to support the NHPS and will raise efficiency and overall quality as well. However, this does not seem to be on the agenda. Just access to healthcare is not enough; it has to be accessible, affordable, available, timely and of good quality,” Dr Dass avers.

However, that does not change the fact that such a scheme is the need of the hour and, when implemented, can significantly reduce disease burden for the ordinary Indian, she remarks.

Make health insurance mandatory: Dr K K Aggarwal

The NHPS is likely to have a ripple effect for insurance companies and the banking sector. Explaining the possibility, Dr K K Aggarwal, president of the Heart Care Foundation and former national president of the Indian Medical Association (IMA), says, “Once the scheme starts, the rich too will get themselves insured. In fact, the government should make insurance compulsory, where it will pay for the poor while in the remaining cases, either the person or the employer pays it.” Arguing in favour of such a compulsion, he asks, “When you do not allow any car on the road without insurance, how do you allow a person without it?”

The project will fail if the claim is not reimbursed on time, Dr Aggarwal warns, adding, “Currently, their job is to find faults and deduct reimbursements.” Another challenge, he feels, is the OPD services, which can be managed with the wellness centres. “The success of this project will depend on the success of wellness programmes,” he adds.

Identifying the target group

The NHPS targets the secondary and tertiary healthcare needs of the underprivileged arising as a consequence of epidemiological transitions. But, how will the vulnerable class be identified? The government plans to take the Socio-Economic Caste Census, 2011, as the benchmark. However, its findings need to be verified, as the responses contained in it are given by individuals (revealed to the enumerator visiting the family). Moreover, the findings of the caste census have not been made public yet. Another issue is the fact that this is an entitlement-based scheme, which is decided on the grounds of laid-down deprivation criteria, which are highly subjective and prone to manipulations.

As pointed out by experts, this scheme does not outpatient services and lays stress on indoor facilities. This can put further burden on the existing hospital infrastructure. A lack of infrastructure and human resources – medical, nursing and paramedical – in government’s rural set-up will indirectly help drive private health sector, which ironically will be an antithesis to the genesis of the scheme. The NITI Aayog is contemplating developing an IT platform to handle different aspects of this complex and monumental scheme, but how it meets the challenges envisaged by the healthcare industry will be the key to its success.

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