Date Published: March 7, 2019
Publisher: Public Library of Science
Author(s): Blake J. Angell, Shankar Prinja, Anadi Gupt, Vivekanand Jha, Stephen Jan
Abstract: In an Essay, Blake Angell and colleagues discuss ambitious reforms planned to expand coverage of the health system in India.
Partial Text: Successive Indian national governments have stated a commitment to achieving universal health coverage (UHC). In spite of this, UHC remains an elusive aim, and the Indian health system continues to be characterised by substantial shortcomings relating to workforce, infrastructure, and the quality and availability of services. Public expenditure on healthcare in India remains at levels amongst the lowest in the world. The government of India approved the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in March 2018 and has hailed the program as a historic step towards achieving UHC in India. The scheme aims to publicly fund the healthcare of up to 500 million people and, if it lives up to its potential, represents a unique opportunity to institutionalise quality healthcare free at the point of service for the most marginalised Indians, improving the health of the population and drastically reducing or eliminating medical-related impoverishment. While many have already questioned the likelihood of successful implementation of the AB-PMJAY, the vast ambition of the program presents an opportunity to pursue the systemic reform that India requires to meet its UHC aims. This will require an injection of resources into a chronically underfunded health system, but this must be accompanied by a focus on the interrelated issues of governance, quality control, and stewardship if the scheme is to sustainably accelerate India towards UHC.
The Indian health system comprises a complex mix of various levels of government decision makers and providers, private companies, and other nongovernment service providers. The country has a chronic shortage of doctors and other healthcare providers, who tend to be concentrated in the urban centres, leaving large parts of the country underserved [1,2]. Notwithstanding increases in real terms over recent decades, government expenditure on health in India ranks amongst the lowest in the world at a little over 1% of GDP . Consequently, the system depends heavily on out-of-pocket payments charged to patients at the point of care. Such payments limit access to care and have a disproportionate economic impact on the poor . Impoverishment in India as a result of healthcare costs is common for patients and their families, with an estimated 50–60 million people pushed into poverty each year as a result of medical-related expenditure .
In this context, the cabinet of the Indian government approved the ambitious AB-PMJAY in March, 2018. The scheme, colloquially referred to as “Modicare” after Indian Prime Minister Narendra Modi, aims to build on existing schemes to provide publicly funded health insurance cover of up to 500,000 Indian rupees (over US$7,000) per family per year to about 100 million families (500 million people, 40% of India’s population) [14,15]. The scheme builds on the previous programs outlined above (for example, the National Health Mission still forms the basis of primary care under the new program ) and has been designed to be implemented to either take over or operate alongside state-based programs, but has a broader remit in terms of the services covered and the amount of coverage that each individual is entitled to. The government has so far allocated 100 billion rupees (almost US$1.5 billion) to the program for 2018–2019 and 2019–2020 . Currently, the country spends about US$64 per person on healthcare, two-thirds of which is privately financed by user fees . As such, current UHC initiatives in India centred on AB-PMJAY alongside state-based programs such as those in Andhra Pradesh, Telangana, Tamil Nadu, Karnataka, and Kerala represent, as a whole, one of the most ambitious ever health and, one could argue, poverty-alleviation programs ever launched.
UHC aims to ensure access to quality essential healthcare services and medicines for populations without exposing them to the risk of financial hardship . Progress towards UHC must be seen in light of the severe challenges facing the Indian system. The country is beset by deficiencies in the resources available to fund healthcare, the skilled workforce and infrastructure available to provide care, and oversight of healthcare provision. Private providers have become the dominant provider of care in India, and thus UHC is unlikely to be achieved without engagement with this sector [2,23,24]. The profit motive that drives the behaviour of these providers, however, has led to concerns that services may be encouraged to sometimes act against the public interest. Regulation and oversight of these providers in low- and middle-income nations is often poor. There is evidence from across low- and middle-income countries that private providers more frequently deviate from evidence-based practice, have poorer patient outcomes, and are more likely to provide unnecessary testing and treatment , and the data that do exist from India have mirrored these findings . At the same time, public providers in India have been shown to face significant governance challenges as well, with services shown to be rife with absenteeism, of poor quality, and nonexistent in many areas of care. Corruption at all levels of the system from doctor training to investment decisions remains an issue .
The AB-PMJAY offers a unique opportunity to improve the health of hundreds of millions of Indians and eliminate a major source of poverty afflicting the nation. There are, however, substantial challenges that need to be overcome to enable these benefits to be realised by the Indian population and ensure that the scheme makes a sustainable contribution to the progress of India towards UHC. UHC has become a key guiding target for health systems around the world under the Sustainable Development Goals to improve the health of the global population and overcome the scourge of medical-related impoverishment. The success of UHC is measured by the access of health services across the population, the types of services that are available, and the financial protection offered to the population. While there are obvious resource constraints in implementing AB-PMJAY, the success—or otherwise—of the scheme in making progress across these three measures will also depend on overcoming a number of existing and interrelated structural deficiencies of the Indian system such as issues of public and private sector governance, stewardship, quality control, and health system organisation. To do so will require careful monitoring of the implementation of the program to track progress against key budgetary, service, and financial-protection measures and guard against unintended consequences. In many cases, current arrangements in these areas can be seen to be a product of vested interests and a system that is not designed to reward positive change. Altering these incentives to promote universal and quality care for all Indians will require widespread reform, intervention, and leadership across all levels of the Indian system. Thus, whilst these weaknesses pose a threat to the ability of proposed reforms to meet their ambitious objectives, by providing the impetus for systemic reform, AB-PMJAY presents the nation with a chance to tackle long-term and embedded shortcomings in governance, quality control, and stewardship.