Ayushman Bharat, announced in the Union Budget 2018, provides the thrust for India’s journey towards universal health coverage (UHC), with an eye on the upcoming 2019 general elections and expanding significantly from the past programme, the Rashtriya Swasthya Bima Yojana (RSBY). While allocations in the Budget under UHC for converting sub-centres into centres for delivering comprehensive primary healthcare is a welcome step, the challenge is in equipping the centres with trained health personnel for not only providing diagnostic and treatment services for communicable and non-communicable diseases, but also for promoting disease prevention and community-based health facilities that take care of emerging health problems of young and old population, including mental illness, chronic health burden and end of life care, etc. Is India ready to meet the cost of ramping up the health system, providing health workers at all levels and in allied services, is a critical question? Answers to it are imperative for revitalising health services.
The government has proposed a significant increase in the expansion for insurance of 100 million poor and vulnerable families, providing to nearly 40% of the population and becoming the world’s largest health assurance cover provider under the National Health Protection Mission (NHPM). Each individual gets an annual allocation of Rs 5 lakh for secondary and tertiary hospitalisation. The move is expected to benefit as many as 500 million people, going much beyond a total of 36 million families who have been enrolled so far under RSBY. Question arises how the government plans to pay for the increase in the number of people who are provided a mandatory amount of free healthcare cover? There is hope in Arun Jaitley’s statement that “adequate funds will be provided for the smooth implementation of this programme,” and in the initial announcement by the finance ministry of an outlay of Rs 2,000 crore. With the Union health ministry announcing a few days ago an allocation of Rs 10,000 crore for the next two years towards Modicare—as this initiative is being popularly called—there are expectations of more funds’ availability in the future, if one is to believe JP Nadda, the Union health minister.
Besides the allocation of funds, there is requirement for increasing the provision of hospitals for secondary and tertiary care, along with available package of services with adequate and appropriate quality of care through primary healthcare. The government’s call for the upgrade of 24 district hospitals for hosting new medical colleges in states that currently have few will not only improve the capacity for delivering advanced care closer to home, but also scale up availability of doctors, nurses and paramedics. Also, priority is being given to strengthening primary healthcare with 70% of allocated funds being spent on it, which means a better basic healthcare package for the people. It is envisioned that health centres will be upgraded to 1.5 lakh health and wellness centres. The Budget proposal of using Rs 1,200 crore to convert 1.5 lakh sub-centres into active delivery points for comprehensive primary health services can go a long way—moving from largely antenatal care, immunisation and access to contraceptives, to disease prevention, providing diagnostic and treatment services and also encouraging community-based health promotion, which is particularly beneficial for dealing with communicable and non-communicable diseases.
Clearly, the new focus aims to take primary health centres from providing only limited services that represent less than 10% of all morbidities, as in the past, to comprehensive healthcare close to the community covering services related to pregnancy and child birth, neonatal and infant health, childhood and adolescent health, family planning and reproductive health, ophthalmic and ENT problems, oral health, mental health ailments, elderly and palliative health, emergency medical services, management of communicable and non-communicable diseases as well as general outpatient care, along with free essential medicines and diagnostics, teleconsultation and provision for electronic health records.
Of course, a challenge in building a strong public health system will be in attracting and retaining human resources in rural and remote areas, and within public services. One way is to have regular appointments at medical personnels’ home districts, with attractive incentives that are enforced and delivered, and not have contractual employment or leniency in making these posts mandatory for a certain term. This has worked in some of the Asian countries and there seems to be no reason why it should not in India. We need a powerful human resource strategy, and in addition to the need for strengthening the public healthcare system, there is strong requirement for regulating the private healthcare market—as UHC will bring a neat nexus between public and private healthcare institutions. Regulatory mechanisms for the private and public health sector have to be adequate to ensure quality of care and have robust health system responses, otherwise UHC will remain a challenge.
By: Mala Kapur Shankardass
Associate professor, Maitreyi College, University of Delhi