Reversing health sector neglect

HEALTH / GOVERNANCE

Topic: General Studies 2:

• Issues relating to development and management of Social Sector/Services relating to Health

Reversing health sector neglect

Context: The pandemic has highlighted the need for effective universal health coverage (UHC) 

What steps have been taken by government to achieve UHC?

• The government is poised to employ Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY) health insurance as the tool for achieving UHC.
• Plans are reportedly under way to extend coverage to the non-poor population under AB-PM-JAY, which currently covers the bottom 40% of the population. 

Challenges/Criticism of Government’s approach on achieving UHC

• Private Sector Prioritised: Taking the health insurance route to UHC driven by private players, rather than strengthening the public provisioning of health care, is reflective of the non-negotiability of private health care in India. 
• Urban Bias in Private Health Services: There is stark maldistribution of private health-care facilities -almost two-thirds of corporate hospitals concentrated in major cities 
• Coverage doesn’t ensure access: Low budgetary appropriations for insurance could mean that universal insurance does not translate to universal access to services, much akin to what was seen under the Affordable Care Act in the U.S. 
• Experience points to different direction: Insurance-based incentives to drive private players into the rural countryside have been largely unsuccessful, and experience suggests that the public sector could be the only effective alternative. 
• Little homework before expansion: Envisaging universal health insurance without enough regulatory robustness to handle everything from malpractices to monopolistic tendencies, will only lead to distorted results. 
• Need for Legislations: Government should enact ‘Clinical Establishments Act’ for effective monitoring & compliance, before embarking on a universal scheme involving large-scale public-private collaboration
• Path-dependent resistance to reform: The bigger and deeper the reform, the more the resistance. Covering the remaining population under the AB-PM-JAY presents massive fiscal and design challenges.
• Fiscal Challenges: Meeting requirements of Universalisation through general revenue financing would greatly strain the exchequer and looks very unlikely especially in the immediate aftermath of the pandemic.
• Administrative Challenges: Turning AB-PM-JAY into a contributory scheme based on premium collections would be a costly and daunting undertaking, given the huge informal sector and possible adverse selection problems.

• Technical Challenges: Harmonising benefits and entitlements among various beneficiary groups, and a formalisation and consolidation of practices in a likely situation of covering outpatient care, are formidable additional challenges

• Challenges with National Digital Health Mission (NDHM) that complements the UHC Scheme
  • Integration and improved management of patient and health facility information are very welcome. 
  • However, in the absence of robust ground-level documentation practices and its prerequisites, it would do little more than helping some private players and adding to administrative complexity and costs like the electronic health records did under the US ACA.

Way Ahead

• While upheavals offer windows for pushing reform, a protracted presence of the pandemic in the country could undermine its gravity and the perceived urgency for major reform.
• Civil society would need to utilise this opening to generate widespread public consensus and pressure for health-care reform
• At the same time, politics would need to recognise the unprecedented populist significance of health and marshal enough will to negotiate organised opposition to change.

Connecting the dots

• Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY)