Well begun but half done

Ayushman Bharat is arguably one of the most disruptive health schemes of the new millennium in India. A country of more than 1.3 billion people do need such a bold initiative, to provide access to appropriate and affordable health care to population spread across vast geographic area with diverse culture and health-care needs. Ayushman Bharat envisages two initiatives: Health and wellness centres and National Health Protection Scheme (NHPS). The Health and wellness centres with free diagnostics and medicine are certainly a welcome move to ensure that comprehensive primary healthcare is available to citizens within walking distance from their homes and businesses. At the same time, the flagship NHPS would take care of secondary and tertiary care and would provide citizens with a financial cushion against catastrophic expenses in events of hospitalisation.

But, first we need to answer the following questions – What is new in this scheme which was lacking in earlier flagship health schemes like National Rural Health Mission and Rashtriya Swasthya Bima Yojana? Why have we not been able to provide comprehensive universal health coverage to our citizens? Why did we fail to provide financial risk protection to our poor and vulnerable fellow countrymen? The answer to these questions lies in understanding the need of the poorest and weakest section of the society.

Healthcare need is not only uncertain and unpredictable but also catastrophic to households living on the margins. These poor households not only spend money out of pocket due to health events but also have to suffer wage loss to seek healthcare either through consultations or on account of hospitalisations. Evidence suggests in our country that more than 60 per cent of the healthcare episodes are dealt through outpatient consultations. Studies show that catastrophic health care expenses and events lead to more than 50 million families falling below the poverty line every year in absence of financial risk protection.

But we fail to understand even in presence of strong evidence that not only hospitalisation but also outpatient care leads to the impoverishment of households. For families living on daily wages, hospitalisation probably is the last option in an illness episode as it not only leads to catastrophic expenses but also leads to loss of wages of more than one earning member of the family. Hence, any scheme favouring hospitalisation over outpatient care and coverage is not an appropriate product for these vulnerable and poor households.

Another point to consider is about improved healthcare access through insurance like product leading to two distinct events. Improved access will certainly help households and families to fulfil their unmet healthcare needs, but not at zero cost. From our personal experience, we know that healthcare consultations unleash additional demands for health like care for co-morbidities and patient support services and many of these services are not covered in insurance products. Hence, the possibility of an increase in households out of pocket expenditure cannot be ruled out with increased access, because as highlighted earlier the product that is offered under NHPS is geared towards secondary and tertiary inpatient care over comprehensive outpatient care and preventive services. Finally, with increasing longevity in the country, we are now seeing an epidemiological transition towards non-communicable diseases like hypertension, diabetes, mental illnesses and other co-morbidities. These conditions require long-term care and are best managed through comprehensive primary care provided in the outpatient setting.

Hence, we need to understand that our responsibility is not over by providing financial risk cover against hospitalisation to poor and vulnerable households. We need to learn from our experiences of RSBY scheme, that we need to customise our product well. Healthcare needs are diverse. We should provide appropriate benefit packages to our beneficiaries by factoring in their social and economic context and their healthcare needs. For example, we need to consider outpatient care, medicine and diagnostic charges; travel allowance and most importantly wage loss compensation as essential ingredients of the benefit package and not just hospitalisation expenses. We also know that enrolment rates of target beneficiaries in the earlier schemes was limited mainly of account of both, lack of awareness about the scheme as well as limited service provider network. Low enrolment rates defeat the very purpose of the insurance schemes of providing free access to care to the beneficiaries.

Hence, community awareness campaigns not only for the insurance scheme but also on healthy lifestyle are very much needed. Lastly, the package of services under any insurance scheme should be a dynamic list and should take into account the epidemiological transition that we are witnessing. We also need to customise our benefit package to take care of needs of special groups like, elderly who are on long-term medication support through outpatient services on account of non-communicable disease, support for children with special needs, people requiring long-term rehabilitation, victims of road traffic accidents and others.

If resources permit, the benefit package may also be extended to include interventions or products that promote healthy lifestyle and immunisation services especially the ones which are not available through universal immunisation programme. We also need to direct our attention towards addressing the limitation of our existing healthcare programs and insurance schemes. We strongly believe that Ayushman Bharat scheme will provide much-needed impetus towards progressive realisation of universal health coverage.

The author is a faculty at the Indian Institute of Public Health-Delhi, Public Health Foundation of India (PHFI). Views expressed are personal.