In India, can universal health care become a reality?

KATHMANDU — Earlier this year, India unravelled an ambitious plan to give almost half the country’s population free access to health care, which would make it the largest government-funded scheme in the world.

The National Health Protection Mission, dubbed “Modicare” after the country’s Prime Minister Narendra Modi, would offer 100 million families, or about 500 million people living in poverty, up to 500,000 rupees ($7,011) of coverage each year.

If rolled out effectively, the NHPM would be a significant step toward achieving universal health coverage, a key Sustainable Development Goal for 2030. While Modi has announced the program will be launched later in the month, experts wonder whether the program can truly get off the ground.

Every year, 55 million Indians are propelled into poverty because of out-of-pocket expenditure on health care, primarily medicine costs. The country currently spend just 1.4 percent of its gross domestic product on health care — one of the lowest expenditures in the world. Last year, however, the country released its new National Health Policy, the first in 14 years, and pledged to boost health care spending up to 2.5 percent by 2025.

While care in government-run hospitals is technically free for everyone, the system is marred by long queues, poor quality of care, and a lack of human resources.

India has allocated $1.54 billion for the scheme, with insurance payments to be shared between the central and state governments. The program would allow people to visit the country’s network of secondary and tertiary level private hospitals and facilities for care ranging from hip replacements to cancer treatment.

“This is a very encouraging plan. You’re seeing signs that the government is taking health seriously,” Robert Yates, director of the UHC policy forum at Chatham House, told Devex.  

Priya Balasubramaniam, senior public health scientist and director of the Public Health Foundation of India’s Universal Health Initiative, agrees.

“It’s a great beginning. It speaks to the fact the Indian health care system has been chronically underfunded. Preventing people from falling into poverty is a much-wanted action plan,” she said.

But while experts Devex spoke to welcomed the scheme, saying if implemented well it would save lives and improve financial security, they also warned that much remains to be seen. “A lot is in the implementation and the government putting its money where its mouth is,” said Yates.

The role of the private sector

The private sector has grown exponentially over the past decade and currently provides almost 80 percent of outpatient and 60 percent of inpatient care in India.

One key question of India’s new insurance scheme is how the government will engage with the private sector.

Will the private sector be used to fill the gaps in the largely dysfunctional public health care system? Will the government purchase services from the private sector as outlined in the country’s NHP? Will the country see more public-private partnerships spring up?

India’s NHP called for the “strategic purchasing” of private care to bridge critical gaps in public health facilities. Government purchasing is intended to “create a demand for the private health care sector, in alignment with public health goals,” the policy states. “Such strategic purchasing would play a stewardship role in directing private investment towards those areas and those services for which there are currently no providers or few providers.”

Ashok Agarwal, founder of the Indian Institute of Health Management Research, believes that if the scheme is rolled out effectively, demand for services will translate to more private facilities being built.

“Not all people are accessing the private sector because they don’t have money. If they’re then offered it for free, people will flock to it,” he said.

“Simply put, people will go to the private sector thinking it’s better than the public system.”

But it’s the rural areas of India which desperately need more facilities and human resources — areas in which others doubt the private sector will be interested in setting up shop, regardless of government financial incentives.

“The private sector will go after the money. Private doctors do not want to work in rural areas,” Yates said.

Instead, some envision a new genre of health care taking hold in India: Health systems disruptors, otherwise known as nontraditional public-private partnerships. This includes private sector innovators who have created low-cost technologies that have lowered the financial burden of diagnostics, according to Balasubramaniam.

“There has to be a studied, judicious way of looking at how the private sector can be co-opted in the delivery of public health,” she said.

“Based on that, states can make a choice on where to invest more money.”

She stressed that this would require careful monitoring, however, and the presence of an autonomous national health trust.  

Lack of regulation

The private sector in India has been able to grow at an unprecedented pace because it remains largely unregulated.  

Oommen Kurian, public health fellow at the Observer Research Foundation, an independent think tank in India, says the private sector exerts huge economic and lobbying power in India.

“Basically, patients have no idea what procedures they need and when you really don’t need a surgery, you’re convinced by the doctor that it’s necessary, while the doctor gets a cut from the hospital chain,” he said.

“There’s no accountability,” he added.

To that end, experts hope that the scheme will provide an opportunity for the private sector to be standardized — enabling it to have some level of transparency and accountability. This could include only allowing hospitals that meet certain quality standards to be able to serve NHPM beneficiaries; measuring quality of services by patient outcomes rather than the infrastructure; reviewing medical records to ensure surgery and other medical procedures carried out are warranted; and reducing incentives for hospitals to provide care to make more money.

“By amalgamating a sector which has been allowed to exponentially grow like a free market economy, having a scheme like this which may engage the private sector on terms which are fair and ethical will enable states to have better monitoring and stewardship,” Balasubramaniam said.

Kurian agrees.

“Having a strong campaign for the regulation of the sector that is supported by strong players in the sector is, for me, the heart of the matter,” he said.  

Strengthening prevention

Private sector aside, concerns have been raised that the NHPM will only cover in-patient care — that it won’t do anything to actually prevent health problems.

A large proportion of out-of-pocket expenditure is people buying drugs for chronic diseases — which are burgeoning with the country’s changing burden of disease.

“The plan can alleviate catastrophic expenditure on health that may occur suddenly, but it cannot, in my opinion, sustain a healthy population,” Balasubramaniam said.

Yates says India must invest in primary health care, essential to keeping access to health care equitable and affordable. Though the initial health policy proposed installing 150,000 health and wellness centers across the country, Yates said those could fall to the wayside amid plans for the health protection scheme.

“One fears that with the hospital scheme grabbing headlines and big financial interests of private hospitals, that when it comes to allocating a budget, the bulk of attention will be on that. One really wonders whether the health and wellness centers will get the resources they really require,” Yates said.

Recognizing India’s changing burden of disease, the centers, which would be a revamp of the existing primary health system, will provide care for noncommunicable diseases, maternal and child health services, free essential drugs, and diagnostic services.

The centers will be first point of contact with the public health system and better versions of the exiting primary health centers and subcenters that exist across India — currently providing pregnancy care, immunization, and some basic disease treatment.

“The reason the public sector has underperformed is because there’s been no money spent on it. The public health system — particularly in rural India — can be regenerated. Two things that are missing is public financing and political commitment — you need the later for the former,” said Yates.

Balasubramaniam says the establishment of such centers would be critical, particularly in rural and remote areas where states are currently the only entities to have capacity of scale and reach. To this end, it is essential that such centers have the human resources they require. Across India, public health facilities, from the primary to tertiary level, are hampered by severe staff shortages, exceeding 50 percent in some rural areas.

Big data

Looking ahead, experts say the NHPM must be both easy to enrol in and easy to access. Aadhaar, the world’s largest biometric ID system recently rolled out in India, could be used to verify people’s eligibility and enrol at a large scale.

To this end, Agarwal says the way the insurance scheme is explained to people will be key.

“People have to be informed properly in a language and manner they understand,” he said.

“It has to be planned very well.”

Given the coverage scheme will have access to the health information of half a billion people, Agarwal says such data must be used effectively to inform and assess future health policies. Ensuring the responsible use of data and safeguarding will be critical — it’s an issue that has repeatedly surfaced in the wake of reported government identity security breaches. But the potential such data could have is unprecedented, from understanding which treatments are most effective, to understanding Indians’ health-seeking behavior.  

Looking ahead, while it’s early days, if India’s NHPM is properly financed and implemented efficiently, experts agree it has the potential to become the cornerstone of the country’s health care system now and in the years to come.

Update, September 5, 2018: This article has been updated to reflect that the name of the coverage scheme was changed to the National Health Protection Mission (NHPM).  

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