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Dr. Dharminder Nagar

Dr. Dharminder Nagar, MD, Paras Healthcare.

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Will Modicare or NHPS Bridge the Healthcare Gap for India?

For a country that spends less than 1% on public health, the announcement of introducing the world’s largest government funded healthcare program of Rs 1200 crore, makes Indians optimistic about making the right to specialized quality healthcare a reality for all.

With the announcement to cover 500 million people under the National Health Protection Scheme (NHPS) or ‘Modicare’, the Indian healthcare is finally acknowledging and moving forward on the path of providing Universal Healthcare Coverage. For a country that spends less than 1% on public health, the announcement of introducing the world’s largest government funded healthcare program of Rs 1200 crore, makes Indians optimistic about making the right to specialized quality healthcare a reality for all. For years healthcare stakeholders involved in public and private care have pondered over the road map to achieve Universal Healthcare Coverage and finally an ambitious scheme that covers 41.3% of the population and provide Rs 5 lakh health coverage for the entire family looks like a good beginning to a marathon leading to Swasth Bharat.

With the new 1% health and education cess funding the project of more than Rs 11000 crores and empowering the poor common man with specialized treatment with premiums at Rs 1100 per family, the Union Government has set the stage by increasing the federal health budget by 11.5% for 2018-19. The political awareness, the directional approach and the realization of considering the importance of healthcare an aspect of national importance is commendable. India is definitely rising, shining and coming through to highlight ‘Healthcare Matters’.

However, just as the Niti Ayog announces that it shall be preparing and presenting an operational plan soon and unconfirmed sources of the government give a scoop to the media, three people are left puzzled – the healthcare provider, the insurance providers and last the taxpaying citizen of the country.

As I, a private healthcare provider, actively pursuing the nation’s vision of bridging the gap and providing accessible, affordable, quality care to the common man, ponders over the mammoth task of rolling out a project that could change the paradigms of healthcare for the poor, the odds at this point of time seem confusing to me. I am not too convinced, at the moment, but I am optimistic that even after a few glitches, good initiatives will prevail. The issues that the Ayog and the on ground implementation of the scheme could face can be divided into three parameters – Operational, Ideological and Financial.

Let’s talk about the questions surrounding the functioning of ‘Modicare’: Operational

- How will the process be simple for the poor, uneducated and needy patients?

The most challenging task for the Niti Aayog would be to formulate a simple flow that is acceptable and functional for the poor. It is also important to understand that the poor may also be illiterate and may feel lost if asked to read through documents or run from pillar to post for approvals. These are the challenging reasons that make running projects for the poor difficult as implementation, continuity and sustainability are crucial. The same needs to also cover the aspect that this population is transient and travelling to different states for work and livelihood. How will each family be mapped and how will they get the care they have been promised without any delay caused due to bureaucratic paper work?

- Criteria of enrollment of beneficiaries and healthcare providers?

Modicare is yet to introduce the mechanism through which it will be linking the poor population with the healthcare scheme. Moreover with public hospitals being over burdened and private hospitals providing more than 70% of health facilities in India, Modicare is yet to come up with an enrollment and eligibility criteria for hospitals to empanel. Will the midsized hospitals without quality accreditations be empanelled or the corporate hospitals, recognized as leaders in tertiary care, be part of the same, is yet to be decided and made clear.

- The referral or third party administrator path to treatment?

Detecting a poor Indian with an ailment that needs hospitalization would be his onus but what will be the path through which we would get admitted for cashless treatment in a medical facility is as of now an ambiguity. Will the system function with a third party administrator or a referral system will ensure that the poor patient gets the treatment? Who will coordinate the path of the patient and will the process be transparent and include a digital footprint that includes the patient knowing about his treatment approvals?

- How will Modicare include the areas that have no access to specialized care?

Providing cashless treatment to the poor is one aspect and ensuring the accessibility of the same is another. How will the program ensure that the best tertiary care services reach all? The rural to urban healthcare paradox and the absence of tertiary care facility or any healthcare facility in Tier 2 and Tier 3 city is a challenge. Will this include introduction of more medical colleges? The hard reality that money cannot buy health would be staring the planners at Niti Aayog starkly.

Let’s now talk about the speculation on the ideology behind Modicare:

- Is this scheme against the whole concept of the term – Universal Health Coverage?

When you discuss an aspect – Universal Health Coverage, the same highlights the access of affordable, accessible, quality healthcare to the common man, irrespective of socio-economic status. However, the current initiative puts the poor at the forefront and the middle class or even the citizens in the non-taxable slab at a back hand. Wouldn’t a system that decides the cess as per the salary, be a better solution? Why wouldn’t the citizens of the country be ready to pay higher cess to ensure that their interests are protected and that their out of pocket expenses are covered under the insurance. For contributions, there could be a limit set – like those earning below minimum wages should be exempt from contributions and their contributions could be paid by the state.

- Isn’t it important to strengthen the primary care?

As per a Lancet report 65% of the cancers detected in India are in the later stages, putting the patient at a higher risk and reducing the chances of survival. Other than cancer, heart disease, kidney failure and liver disease have high mortality rates due to non existence of robust screening, awareness and prevention oriented programs. With the doctor-patient ratio and bed-to-patient ratios standing at dismal 1:30000 and 0.9/1000 respectively, a good primary healthcare system could help sensitize the population, decrease the tertiary healthcare burden and improve the quality of life of Indians.  However Modicare only stresses on hospitalizations.

- Modicare misses out on the OPD care!

Citing the National Economic Survey, Honorable Finance Minister, Shri Arun Jaitley, had stated that on an average a family has to spend Rs 26,000 per hospitalization case in private hospitals and these statistics highlighted the struggle that millions of Indians have to endure. However, with the insurance industry growing at a rate of 25% per annum, along with organizations providing ESI, corporate insurances to the employees, we see a numerous middle class and salaried Indians opting for insurance to save out of pocket IPD expenses. The tax rebates on health insurance also motivates the business class to opt for cover. However, the crux of Modicare providing Rs 5 lakh coverage to the poor misses the OPD expenses.  With MRI’s and CT Scans costing thousands and even generic medicines seeming out of reach for the poor, will Modicare just promote admissions. Are we looking at another nexus similar to the Rasthriya Swasthya Bima Yojana (RSBY)?

- Why didn’t the government support the already existing ESI Scheme?

The Employee State Insurance Scheme is a robust plan that is backed by pre exitsing laws, infrastructure and support. Second, it is a robust framework that has been neglected and needs to be strengthened – and what better way than to make it universal to make it robust again? Strengthening the ESI would have ensured access to specialized care to a strong salaried class that thrives on a gross salary of or less than Rs 252,000 per annum. Moreover the hospital chain of ESI also ensures that the patients don’t bear the OPD expenses. Why the system was overlooked is still a mystery.

The number game: Financial Implications and Questions

- Is the insurance industry ready?

The IRDA data of 2016-17 stated that there were 8,79,493 number of policies, out of which 8,59,593 claims were paid, highlighting that 2.2% of the insurers did not file any claim. This shows every 1 in 45 people did not file for a claim. With a claim clearance rate of average 91.60% and claim refusal rate of average 6.6%, there are certain insurance companies lagging behind in claim pending statistics. However, with NHPS or Modicare, we are looking at providing care to 100 million and enroll 500 million. Do we have the systems to accommodate such a massive task? Moreover will it be a single private, PPP project or a consortium of various insurance companies paving the way for Modicare?

- Why was the announcement not a part of the National Health Budget?

I can only ponder and speculate and the politically minded can reason the same.

- Contradicting NSSO Data highlighting that the premium of Rs 1200 per family might be too low

The National Sample Survey Office (NSSO) under the Ministry of Statistics and Program Implementation, Government of India, highlights that out of 1000 people, 40 need hospitalization. It also shows that an average expenditure of about Rs 12500 per hospitalization case for the poorest 40%, adding the same annually to Rs 5 lakhs. Hence taking an approximation that 1000 people would comprise of 250 families, the premium of Rs 1200 is insufficient and the same should stand at Rs 2500 minimum. Moreover the data states that the private hospitalization is about 4 times more expensive as in government hospitals. Do these statistics make the private set ups inaccessible to the poor? What will be the final premium cost that the central and the state governments be incurring?

In the end we are all ‘Optimistic Indians’ that wish for order & a framework

The questions are many and as the Niti Ayog works to piece together the jigsaw of healthcare in India, we are optimistic. We definitely want Modicare or NHPS to work. It can be viewed as an initiative that can empower the poor with access to specialized tertiary care which in the future can definitely be amplified to include the middle class. However we can recommend a few aspects too that the Aayog can think worthwhile to include.

1. Need of medical infrastructure and manpower –

The low doctor to population ratio, currently standing at 1:30000 against the WHO recommended ration of 1:1000 and the nurses to patient ratio 1:40 against the worldwide recommendation of 1:4, highlight the shortfall in the manpower. The scenario is grimmer in the tier 2 and tier 3 cities. The medical infrastructure stands no better, with less than 1 bed (0.9) per 1000 in India. The focus should be both, to provide Universal Health Coverage and also ensure its delivery and access. Development of medical colleges and the incorporation of more seats under the DNB programs under the private hospitals will be key.

2. Make the private hospitals venturing in Tier 2 and Tier 3 cities NHPS champions

The players daring to take up the challenging task of providing affordable, accessible, quality specialized care in underserved areas should be considered partners of NHPS. The government should incentivize their operations motivating others also to be vehicles bridging the healthcare gap.

3. Give priority to empanelment of private hospitals in Tier 2 and Tier 3 cities

To ensure access, the NHPS team needs to ensure that the entire focus should be on the tier 2 and tier 3 cities. The empowerment of the poor with access to private hospitals providing specialized care could transform our country.

In the end as the stage is set, let’s begin with a few million and be working spokes that can move the wheel of progression further. Let’s be optimistic that this is a positive step towards achieving a Swasth Bharat. As Robert Frost’s famous poem Woods quotes: ‘The woods are lovely, dark and deep, but I have promises to keep, and miles to go before I sleep,’ our Niti Aayog also has a herculean task of conceiving, implementing and achieving success for the poor Indian.  

Disclaimer: The views expressed in the article above are those of the authors' and do not necessarily represent or reflect the views of this publishing house

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