Before the Finance Minister Arun Jaitley announced the Union Budget for 2018-19, few would have thought that the biggest discussion points would be related to the health sector. Two major initiatives were launched under Ayushman Bharat in this year’s budget speech – health and wellness centres for providing comprehensive primary health care and the National Health Protection Scheme (NHPS).
Although they were less intensely discussed and debated, two additional important announcements pertaining to health were made – the setting up of 24 new medical colleges by upgrading district hospitals and provision of Rs 500 per month for every TB patient.
The first pillar of Ayushman Bharat and perhaps the more important one involves establishing 150,000 health and wellness centres that will provide a broader package of services. Currently, one sub-centre is expected to cater to the health requirements of approximately 5,000 people. However, the services delivered at the sub-centre are focused primarily on maternal and child health as well as treatment of some common illnesses like diarrhoea and respiratory tract infections.
Given that India is facing a double burden of disease including non-communicable diseases like cancer, stroke and diabetes, it is crucial that a more comprehensive gamut of services is delivered at the patients’ first point of contact with the health system. It is therefore proposed that the upgraded sub-centres will provide a comprehensive range of diagnostic, curative, rehabilitative and palliative care as well as preventive and promotive services to address the determinants of ill health like malnutrition and lack of access to sanitation.
While the focus is on NHPS for reducing out-of-pocket expenditure, well-functioning health and wellness centres can also make a significant contribution by providing drugs and diagnostics free of cost. Moreover, travel cost and wage loss can be averted because people will not need to travel long distances to access healthcare.
The proposed health and wellness centres will be run by a team comprising of a mid-level provider along with front-line health workers like the auxiliary nurse midwives and accredited social health activists. The mid-level providers will be nurses or ayush practitioners who will be trained further in public and primary health. The Ministry of Health and Family Welfare in collaboration with the Indira Gandhi National Open University has already rolled out a six-month course for nurses and ayush practitioners in order to create a pool of mid-level providers for leading the health and wellness centres.
Implementation is Key
The scheme, if implemented properly could be a game changer by enhancing access to health care including early detection and treatment services by a large section of society who otherwise could not afford them. The identification of beneficiaries can be done by linking with Aadhar and similarly following up for services received and health outcomes achieved, thereby helping to monitor and evaluate the impact of the programme.
Ultimately, NHPS could help the country move towards universal health coverage and equitable access to healthcare which is one of the UN Sustainable Development Goals or SDGs.
This new scheme builds on the already existing Rashtriya Swasthya Bima Yojna or RSBY – a health insurance scheme for the below poverty line families, with the entitlement of up to Rs 30,000 per annum for diseases requiring hospitalization. However, given that states are expected to agree for 40 percent share under the NHPS and that health being a state subject, state ownership and commitment will be critical to the success of the programme.
The Finance Minister has made a budget allocation at Rs 52,800 crores for the health ministry, up from Rs 47,352 crore during the previous year signifying an increase of 11%, yet as a percentage of the GDP, it is still among the lowest in the world. In addition, government plans increase the levy of health cess from 3 to 4%. According to health minister J P Nadda, Rs 2000 crore has been allocated as of now.
It is clear that the NHPS scheme, which primarily offers support for clinical services such as hospitalization, is unlikely to help fix the broken public health system in the country. The most critical issue remains the limited and uneven distribution of human resources at various levels of health services, with up to 40 percent of health worker posts lying vacant in some states. Most primary health care centres suffer from a perennial shortage of doctors and even district hospitals are without specialists.
Without addressing the human resource situation, public sector health care will remain of poor quality and largely unacceptable, forcing patients to go to the private sector. Therefore, it seems as if NHPS is likely to benefit private parties more than government health services. This will ultimately be unsustainable and even detrimental to the poor for whom the scheme is intended.
Finally, the scheme is innovative and path-breaking in the history of public health in India, which may have a transformative impact if implemented in an effective and coordinated manner. The enduring interest and level of discussion in the media to reflect the wider realization in the country that only healthy people can build a strong and prosperous nation.