Introduction
In 1998, the World Health Assembly made new commitments to ‘Health for All’ for the
21st century. The commitment included, in part, “we commit ourselves to strengthen,
adapting and reforming as appropriate our health systems including essential public
health functions and services to ensure universal access to health services that are
based on scientific evidence of good quality and within affordable limits, and that
are sustainable for the future. We will continue to develop health systems to respond
to the current and anticipated health conditions, socio-economic circumstances and
the needs of people, communities and countries concerned to appropriately manage public
and private actions, and investments in health” [1]
The Government of India and State Governments have the general obligation to extend
free universal health coverage (UHC) services, and ensure that the marginalized sections
of the society should be in a position to obtain quality healthcare services, directly
or indirectly, offered by any healthcare service provider at any given point in time.
The strange thing is India is exporting software to the Western countries, but it
trails in health outcomes when compared with Bangladesh and Sri Lanka! The 11th 5-year
plan has set goals for reducing maternal and infant mortality, increasing child sex
ratio, and reducing malnutrition among children and women in the country. The same
five year includes states health for all marginalized groups at a reasonable cost.
On this issue, the Government of India has set minimum standards and requisite control
mechanisms or systems, focusing on paneled health providers.[2]
Today, health exclusion has become one of the major concerns, because of which inclusive
development is not possible in a country like India. Since time immemorial, poverty
and health problems are intertwined. Poverty plays a very crucial role in the onset
of various simple and complicated health problems. The then planning commission had
estimated that 39 million people are afflicted with various health problems just because
of poverty. Around 47% in rural area and 31% in urban areas people are taking loans
and selling assets just to attend to their health needs. Moreover, the same report
says 20% in urban areas go untreated due to financial constraints and 30% in the case
of rural India.[3]
Providing timely finances for the health and healthcare of the needy is a significant
issue; it is the building block of any health system and critical to a well-performing
healthcare system. As we know, many poor Indian states are struggling to get sufficient
funding for health and healthcare needs. Moreover, many developed Indian states have
still not scientifically prearranged their different health services to make sure
equitable, affordable and easily accessible and universal healthcare for all walks
of life and geographies.[4]
Also, the health sector in India suffers from inadequate funding, shortage of skilled
health professionals, failure of the health programs, issues in healthcare management,
weak institutional regulatory system, and neglecting traditional systems of medicines.
Today, the healthcare system has become highly commercialized, and only the rich people
can access quality healthcare. It is also quite evident to write that the healthcare
system in the country suffers from poor health infrastructure, especially in rural
and tribal settings. Even today in rural areas, people are not getting quality health
services because of poor management and lack of infrastructure in rural-based government
hospitals as per the recent Niti Aayog report. There are interstate disparities and
differences between rural and urban health indicators in India. There is a target
to provide safety, health and environment to its citizens through universal quality
healthcare services, and regulatory mechanisms in the part of the private healthcare
sector, by the year 2025; also, to increase the GDP allocation for the health sector
gradually.[5]
Aayushman Bharat is an iconic UHC Program of India to fulfil its promise in the National
Health Policy of 2017. Ayushman Bharat Yojana or National Health Protection Scheme
is a program to provide quality healthcare services to more than half of the total
underserved Indian population. The socioeconomic caste census database shall be utilized
to recognize needy beneficiaries for this scheme in the country. As we know in India,
expenditure on healthcare for the year 2013–2014 was about around 4.02% of the total
GDP, and the government share was just 1.15% against 5.99% of the global average.
The government is committed to hiking money for UHC in budgetary allocations of 2.5
percent of GDP by 2025.[6] Currently, India is using 0.1% of total GDP for the health sector for the purpose
of health inclusion. The National Health Policy of 2017 governments is intended to
spend at least 70% of the total healthcare budget for only primary healthcare centers
(PHCs) ([Figs. 1]
[2]
[3]).
Fig. 1 Out-of-pocket health expenditure as proportion of total health expenditure.
Fig. 2 Government health expenditure as proportion of GDP.
Fig. 3 Population coverage under various health schemes in India.
This new UHC health scheme is a much awaited health program because it reduces the
catastrophic health expenditure on the part of the poor patient, and it also indirectly
helps the quality services on the part of the government hospitals. Ayushman Bharat
has two major segments–1. National Health Protection Scheme and 2. creation of wellness
centers in place of subcenters. The national health protection scheme has two major
agendas–1. pressing the need for good network among health and wellness infrastructure
across the country to deliver quality healthcare services and 2. the most important
point is to deliver integrated healthcare service through insurance coverage, covering,
at least, 50% of India's population who are under below the poverty line or deprived
sections.[7]
In India, the majority of marginalized sections are deprived of quality secondary
and tertiary healthcare services. The basic idea of introducing a new National Health
Protection Scheme is to provide cashless treatment to the marginalized people in any
government or private hospitals, including secondary and tertiary healthcare services.
Earlier, we had subcenters ahead of PHCs. Now, wellness centers will replace the subcenters,
expecting a key role, especially in the rural parts of the country. Still, it is an
unanswered question as to why people will not choose government hospitals for their
health needs over a period of time despite government hospitals doing really well
in some areas. Also, in India, people visiting the PHCs first would rather visit the
secondary and tertiary healthcare centers directly for their various simple health
needs without any referral. It is a topic for the study. In US/Europe, it is not possible,
unless one has a strong referral from the lower healthcare facility.[8]
If the people visit the PHCs immediately for their health needs, the burden on the
secondary and tertiary healthcare will automatically be reduced. Keeping this in mind,
the government has created wellness centers to provide primary healthcare education
and services. Meanwhile, various state governments also have introduced different
health insurance schemes that should not interfere with the Ayushman Bharat scheme
which cause a kind of confusion among people. There are some issues like the referral
system. If anyone wants to get benefits under the Aayushman Bharat scheme in private
hospitals, they must have the referral slip from any government. hospital. Here, if
the required service is not available in the government hospital, only then should
the patient be given the referral slip to go to the higher medical center. This is
not happening. Patients pay bribes to get referral slips from government hospitals;
sometimes, through political influence too. It shows people still do not have any
faith in government hospitals. This leads to having a kind of institutional corruption
in the scheme.[9]
There is one more argument that this scheme is only helpful to the insurance companies,
enriching their profit. However, this concern is a totally unestablished theory to
date. It is found that most of the states are actually willing to go with a legal
trust mode, focusing on a high-volume, low-margin model. For insurance companies,
there is a legal provision in the basic contract such that the insurance companies
can make 15% profit out of the total premiums.[6] Due to heavy competition and nonprofit, insurance companies are asking for comparative
premiums under UHC. Another question was the lack of supply to match the demand generated
after implementing the UHC scheme. Experts opine the new demand may be met through
existing capacity with the private sector in a more efficient manner or government.
health institutes could need more infrastructure and manpower capacity soon.[10]
Quality is an essential contributor to the UHC efforts with stress on grounded technical
work that can be contextualized and simulated across all government hospitals. Cross-cutting
technical areas with clear linkages with quality UHC is a necessity in case of public
health functions and health-related issues. There is a big issue that the majority
of government hospitals are providing free health services including tertiary healthcare.
Still, the majority of patients are spending a lot of money from their pockets for
their health needs. Hi-tech facilities are not being offered by any government hospitals
including CT/MRI scans and other higher end services. Sometimes, required pathological
laboratory and other diagnostic services are available even in the urban-based secondary/tertiary
care government hospitals. In this situation, every patient should go to the private
centers for diagnostic service, drugs and implants, according to the need. It is also
better to note that all public hospitals charge a user fee for the major health issues,
including heart, cancer care kidney, liver, etc.[11]
Health is highly unsure and changeable; moreover, it is catastrophic to the poor families.
Poor households not only spend huge money for their healthcare needs but also suffer
wage loss to get their health back. Some health experts have argued that this UHC
scheme is not able to reduce catastrophic expenditure on the part of the patient.
Hence, this is the time to doubly ensure effectively reducing catastrophic expenditure
through UHC. The UHC health benefit scheme covers around Rs. 5 lakh which is sufficient
to provide any type of healthcare /treatment in all types of hospitalization conditions.
Moreover, this benefit package covers mostly every health condition that requires
hospitalization, daycare, and surgeries, etc. The payment system has been designed
to cover all the costs, and the patient is not needed to pay anything from his/her
pocket at any point of time. Health economists say the scheme is going to increase
the cost of healthcare. However, the proposed UHC will considerably manage the cost
of health service by moving toward a high-volume, low-margin model. Hence, UHC is
a really good scheme for the time being.[12]
Will Ayushman Bharat be affordable in the long run? The government should have brought
this scheme long before, and it depends on the strong political will of the next government
or available resource, or how much government is willing to spend in the future and.
Several states have their ongoing healthcare schemes, and they are not showing interest
in joining the current Ayushman Bharat scheme, for example, Delhi government. The
scheme offers some special provisions to all the states like human resources, financial
resources, state-of-the-art facilities, customizable technological platforms, implementation
systems, audit systems, and effective monitoring systems at no additional cost from
the state exchequer. It is generally agreed that we need to have strong information
and communications (ICT) technology because every beneficiary must get nationwide
network hospitals if it is required for the healthcare system.[5]
If we focus exclusively on the primary healthcare sector, then the burden on the secondary
and tertiary healthcare will be lessened. Not only hospitals but it will also be useful
to the family, mentally and financially. The ICT government must focus more on PHCs,
so that any health issues can be solved if we diagnose it in an early stage. It is
also found that the strategic purchasing pathway will be adopted to procure and pay
for secondary and tertiary healthcare services from public and private healthcare
service providers. These two ideas have now been clubbed together in the budget of
2018 to provide the required engine for the India’s big plan toward UHC. However,
there are some experts who opine ‘this scheme addresses the wrong problem or provide
a wrong solution even if it tends to address the right problem.” The government must
opt for the public–private model (PPM) and that would be the best idea for the success
of the Ayushman Bharat scheme[13]
Health economists are of the opinion that the private sector in a UHC scheme is poorly
regulated, and the government needs to focus on strengthening the obligate regulations
on the part of the private sector. The purchaser of the different health services
can play a vital role in making a system strong through their financial power over
the private sector, and now the government is required to focus on the following segments
of the UHC:
-
Setup price system effectively.
-
The proper establishment of the price regulatory mechanism.
-
Focusing on the quality of health services.
-
An incentive to the government hospital to improve quality.
-
Using electronic data sharing system with the help of information technology.[14]
The UHC should be based on the PPM system. Moreover, it ought to be noted that the
government should not use its limited financial and human resources to improve health
services through the private sector. This idea may not be good for the Indian health
system and budget. Private people can make their presence felt in a UHC system, but
their concentration will be only toward the profit motive. Determine understanding
and the part of both the government and private sector, so that the private sector
should make use of their capacity, skill, and financial issues in providing quality
service to the marginalized sections of the society. The private sector in health
healthcare issues is required for their well-organized and capable network. They must
go for reasonable prices and be dictated by service motives.[15]
Remarks
The unifying framework for the UHC should be provided, so that actions at all levels
and by all stakeholders are mutually supportive, Governments and nongovernmental organizations,
health professional associations, etc. should be encouraged to contribute to the implementation
of the process by integrating risk factor control in their health sector strategies.
Multisectoral action is necessary at all stages, because many preventive risk factors
lay outside the direct influence of the health sectors. Other departments and agencies
whose work touches on preventive care must also be mobilized (e.g., customs and excise,
trade and commerce, agriculture, law and justice, labor, transport and public services,
education, and the environment).[18] The key need of concern in fulfilling the aim of UHC includes a well-structured
financing model for quality healthcare delivery; good training for senior health staff
in public health institutes; good package and the cost of healthcare interventions;
and increasing state budget allocations for public health. While substantial applied
research and findings are available today regarding our journey toward UHC, sensible
information to address widespread constraints and support the planned policy, decision
touching health policies remain an area with incomplete insights. Eventually, India
needs sensible solutions to move quantifiable development regarding UHC, and the general
population thinks there’s no better.[16]
Future Research—Must Focus On
-
Reveal the organization, financing, management, and resources to deliver universal
healthcare services in India.
-
Study on health and wellness centers and national health protection schemes under
UHC.
-
Identify the issues and challenges to achieve UHC in the country.
-
Impact of universal healthcare services on promotive, preventive curative, and rehabilitative
health issues, especially for the rural and tribal sections.
Possible drivers of present health inequities within UHC efforts, and possible approaches
to shifting the curve toward proequity strategies
Tentative Conclusion
The most common critique against the Ayushman Bharat scheme is that the government
is not stressing more on preventive and promotive care. However, the real and tough
challenge is how to provide both preventive and curative at the same time. Also, we
need to focus on growing catastrophic health expenditure among the poor people. In
India, normally, people will give up needy treatment because of the cost factor. People
sell their movable and immovable properties just because of medical reasons, putting
them into a cycle of poverty. Hence, the experts opine that the state should focus
more on curative aspects to minimize the burden on the universal healthcare programs.[17] Moreover, it is also very important to bring strong government planning to involve
citizens regarding health behavior change through health communication and evidence-based
health governance. Introducing prevention-based health checkups in every government
health facility is the need of the hour. There is a need for a well-organized referral
system in the rural areas, providing complete services and focusing on primary healthcare.
A well-structured system for occupational health diseases and the introduction of
the concept of occupational healthcare providers is also a must.[18] We need quality mass surveillance of “at risk” and “vulnerable populations” for
some life-threatening diseases like cancer, heart, hypertension, and diabetes on an
urgent basis. More importantly, geographical coverage for endemic diseases are the
need of the hour.
