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Universal Health Coverage

  • On 15th August 2022, independent India will turn 75. In the lifespan of nations, India is still young. The best is surely yet to come. India’s youthful and aspirational population deserves a rapid transformation of the economy, which can deliver double-digit growth, jobs and prosperity to all.
  • The purpose of this, ‘Strategy for New India @ 75’, is to define clear objectives for 2022-23 in a  diverse range of 41 areas that recognize the progress already made; and challenges that remain; identify binding constraints in specific sectors; and suggest the way forward for achieving the stated objectives. 
  • The Strategy document has disaggregated the 41 sectors under four sections: drivers, infrastructure,  inclusion, and governance. 
  • The first section on drivers focuses on the engines of economic performance – in macroeconomic terms with chapters on growth and employment.
  • The section also discusses strategies for the doubling of farmers’ incomes; boosting Make in India; upgrading the science, technology and innovation ecosystem; and promoting sunrise sectors like fintech and tourism.
  • An annual rate of growth of 9 per cent by 2022-23 is essential for generating sufficient jobs and achieving prosperity for all. Four key steps, among others, have been spelled out for achieving this GDP growth rate. These are:

a. Increase the investment rate as measured by gross fixed capital formation (GFCF) from present 29 per cent to 36 per cent of GDP by 2022. About half of this increase must come from public investment which is slated to increase from 4 per cent to 7 per cent of GDP. Government savings have to move into positive territory. This sharp increase in the investment-to-GDP ratio will require significantly higher resource mobilization efforts as elaborated in the chapter on Growth.

b. In agriculture, emphasis must shift to converting farmers to ‘agripreneurs’ by further expanding e-National Agriculture Markets (e-NAMs) and replacing the Agricultural Produce Marketing Committee  (APMC) Act with the Agricultural Produce and Livestock Marketing (APLM) Act. The creation of a unified national market, a freer export regime and the abolition of the Essential Commodities Act are essential for boosting agricultural growth.

c. A strong push would be given to `Zero Budget Natural Farming (ZBNF) techniques that reduce costs,  improve land quality and increase farmers’ incomes. This is a tested method for putting environmental carbon back into the land. Therefore, ZBNF allows India to significantly contribute to reducing the global carbon footprint.

d. To ensure maximum employment creation, codification of labour laws must be completed and a massive effort must be made to upscale apprenticeships.

  • The second section on infrastructure deals with the physical foundations of growth. A lot of progress has been made across all infrastructure sectors. This is crucial to enhancing the competitiveness of Indian business as also ensuring the citizens’ ease of living. Three key steps, among others, are:

a. Expediting the establishment of the Rail Development Authority (RDA), which is already approved. RDA  will advise or make informed decisions on an integrated, transparent and dynamic pricing mechanism for the railways. Investment in railways will be ramped up, including by monetising existing railway assets.

b. The share of freight transported by coastal shipping and inland waterways will be doubled. Initially,  viability gap funding will be provided until the infrastructure is fully developed. An IT-enabled platform would be developed for integrating different modes of transport and promoting multi-modal and digitised mobility.

c. With the completion of the Bharat Net programme in 2019, all 2.5 lakh gram panchayats will be digitally connected. In the next phase the last mile connectivity to the individual villages will be completed. The aim will be to deliver all government services at the state, district, and gram panchayat level digitally by  2022-23, thereby eliminating the digital divide.

  • The section on inclusion deals with the urgent task of investing in the capabilities of all of India’s citizens. The three themes in this section revolve around the various dimensions of health, education and mainstreaming of traditionally marginalized sections of the population. While there are multiple dimensions and pathways  contained in the chapters in this section, four key steps, among others, are:

a. Successfully implementing the Ayushman Bharat programme including the establishment of 150,000  health and wellness centres across the country, and rolling out the Pradhan Mantri Jan Arogya  Abhiyaan.

b. Upgrading the quality of the school education system and skills, including the creation of a new innovation ecosystem at the ground level by establishing at least 10,000 Atal Tinkering Labs by 2020.

c. As already done in rural areas, affordable housing in urban areas will be given a huge push to improve workers’ living conditions and ensure equity while providing a strong impetus to economic growth.

d. Implementing strategies to achieve regional equity by focusing on the North-East region and successfully rolling out the Aspirational Districts Programme.

  • The final section on governance delves deep into how the tasks/business of government can be streamlined and reformed to achieve better outcomes. It involves a sharp focus on ensuring accountability and a shift to performance-based evaluation.
  • The government will revamp its data systems and analysis so that all policy interventions and decision-making are based on evidence and real-time data. This will yield efficient and

targeted delivery of services and justice to those who need them the most.

  • Three key steps, among others, are:

a. Implementing the recommendations of the Second Administrative Reforms Commission as a prelude to appointing a successor for designing reforms in the changing context of emerging technologies and the growing complexity of the economy.

b. A new autonomous body, viz., the Arbitration Council of India, may be set up to grade arbitral institutions and accredit arbitrators to make the arbitration process cost-effective and speedy, and to pre-empt the need for court intervention.

c. The scope of the Swachh Bharat Mission may be expanded to cover initiatives for landfills, plastic waste and municipal waste and generating wealth from waste.

  • To achieve the goals of New India in 2022-23, it is important for the private sector, civil society and even individuals to draw up their own strategies to complement and supplement the steps the government intends to take. With the available tools of 21st-century technology, it should be possible to truly create a mass movement for development. With the Sankalp of all Indians, India will have Siddhi.

Check out our previous blogs on the Strategy for New India at 75:

Objectives

On the strong platform of Pradhan Mantri – Jan Arogya Yojana (PM-JAY):

  • Attain a coverage of at least 75 per cent of the population with publicly financed health insurance (covering most secondary and tertiary care procedures) by 2022-23.
  • Reduce by 50 per cent the proportion of households facing catastrophic health expenditure from the current levels.

Current Situation

  • There have been noteworthy strides over the past two decades in the quality of health care delivered to citizens and population health outcomes. Yet, there is wide variation across states in the availability of resources, the status of state health programmes, rural-urban differentials and governance capacity.
  • Public health infrastructure in the country expanded considerably following the launch of the National Health Mission in 2005; however, there continues to be a shortfall in several areas. In 2015, the number of sub-centres (SCs) fell short of requirements by 20 per cent, of primary health centres (PHCs) by 22 per cent and of community health centres (CHCs) by 32 per cent in rural India. The quality of public sector health facilities has also suffered because of shortage of personnel and lack of necessary supplies.
  • Data from the National Sample Survey Organisation’s 71st Round (January-June 2014) shows that only 28 per cent and 21 per cent of patients in rural and urban areas respectively use the outpatient care provided by health facilities in the public sector. The corresponding figures for the usage of in-patient care are 42 per cent and 32 per cent. The mixed health system, therefore, remains largely dominated by the private sector, which provides services at widely varying costs and quality levels.
  • Public funding of health has been consistently low in India (approximately 1.3 per cent of GDP). As a (RSBY) to cover hospital expenses of up to INR 30,000 for a family of five members living below the poverty line. Evaluation studies for RSBY have shown that while it did increase access to health care as well as non-medical health spending for the poor, it did not provide significant financial protection, perhaps due to the exclusion of spending on outpatient care, drugs and diagnostics.
  • The decision to launch PM-JAY under Ayushman Bharat is a path breaking step towards Universal Health Coverage. It aims to cover 10.74 crore families at the bottom two quintiles with INR 5 lakh cover each year for secondary and tertiary care hospitalization. The PM-JAY will be implemented in alliance with state government schemes.
  • As per the NSSO 71st Round, out of the total OOPE, 63.5 per cent is on outpatient care. Of this, the largest expenditure (71 per cent) is on medicine. It is paradoxical that although India is one of the largest suppliers of generic drugs to the world, a significant proportion of the country’s population lacks access to essential medicines.
  • During the last four years, however, the government has taken significant steps to enhance access to medicines especially for the poor and middle classes. The prices 958 drugs have been capped along with the prices of cardiac stents and knee implants. The Pradhan Mantri Bhartiya Janaushadhi Pariyojana has been expanded from 99 functional stores in May, 2014 to 4,024 functional stores in September, 2018.

Constraints

  1. There has been inadequate focus on comprehensive preventive care and primary care in the past.
  2. The multiplicity of government-sponsored insurance schemes has resulted in the fragmentation of the risk pool. A sizeable risk pool comprising low- and high-risk individuals is imperative to ensure the viability and sustainability of insurance.
  3. Since outpatient care, drugs and diagnostics are not covered under several government insurance schemes, people often delay seeking care until they are severely ill.
  4. The coverage ceiling of RSBY is inadequate.
  5. There is an acute shortage of motivated human resources for health, attributable at least partly to the poor incentives for government providers.
  6. Access to drugs and medical devices at affordable prices is an essential ingredient of Universal Health Coverage. According to estimates by the Central Drugs and Standards Control Organization, around 84 per cent of the active pharmaceutical ingredients (APIs) for drugs manufactured in India are imported. This dependence on import of APIs has gone up more than fourfold between 2004 and 2013.
  7. While the notification of medical devices rules is an important step, a clearly defined and comprehensive regulatory framework is required. Additionally, approximately 75 per cent of the current demand for devices is met through imports
  8. The prices of diagnostic tests can vary widely across the country. For example, a lipid profile test can cost Rs. 90 in some cities, going up to Rs. 7,110 in others.

Way Forward 

Recommendations pertaining to comprehensive primary healthcare, public health action and human resources for health are covered in other chapters of this document. Other strategies for overcoming the constraints listed are described below.

  1. Roll out PM-JAY
  • Establish the Ayushman Bharat-National Health Agency at the central level and counterpart institutions at the state and district levels for management of the PM-JAY.
  • Develop a robust, modular, scalable and interoperable IT platform as per standards formulated by the National Digital Health Authority to enable paperless and cashless transactions under the scheme.
  • Put in place mechanisms for fraud prevention, detection and control as well as for grievance redressal.
  • Design a comprehensive media and outreach strategy to increase awareness of the scheme among intended beneficiaries and other stakeholders.
  • Institutionalise health technology assessment at the central and state levels to determine the service packages to be covered under PM-JAY in the future.
  • Develop costing frameworks for determining accurate package rates for procedures.
  • Develop standard treatment guidelines for priority conditions.
  • Monitoring, evaluation and research

O Put in place data analytics systems to guide strategic purchasing of health services, forecasting and generating policy inputs.

O Institutionalize a mechanism for undertaking independent audits of the scheme.

O Conduct research on the population-level impact of the programme including financial protection, healthcare access and health outcomes.

  1. Galvanize health facilities in the public sector and engage the private sector
  • Provide greater autonomy to public hospitals to use claims money generated under PM-JAY to improve facilities, purchase the necessary drugs/tests and provide performance-based incentives to staff.
  • Strengthen district hospitals to conform to the Indian Public Health Standards.
  • Institutionalize ranking of district hospitals based on their performance on health indicators to foster competition and nudge them towards quality improvement.
  • Introduce appropriate gate-keeping mechanisms for adoption by the proposed health and wellness centres.
  • Reform the compensation system for professionals in public sector health facilities by shifting to a blended capitation mode of payment (part salary and part incentive based on achieving pre-agreed outcomes).
  • Trigger private investments in rural/supply deficit areas by providing appropriate incentives for empanelling hospitals.
  1. Ensure access to affordable drugs and medical devices
  • Institute a new Drug Price Control Order (DPCO), which ensures rational drug prices by reducing trade margins.
  • Include consumables, in addition to drugs, in the DPCO to control undue profiteering.
  • Finalize the national pharmaceutical policy to enable access to affordable medicines, promote the use of generic drugs, clamp down on unfair marketing practices and give a boost to local manufacturing to reduce dependence on imports.
  • Formulate and implement the e-pharmacy policy to facilitate online access to quality medicines in a cost-effective and timely manner.
  • Review and iron out the challenges with the business model of Jan Aushadhi stores to ensure that they can function as self-sustaining entities and scale up rapidly across the country.
  • Find the best pathways for scaling up and adapting the process of bulk procurement of drugs adopted in states like Tamil Nadu and Rajasthan.
  • Boost domestic production of APIs by setting up six large API intermediate clusters as per the recommendations of the Katoch Committee.
  • Streamline regulatory processes including providing a single window clearance mechanism to manufacturers.
  • Introduce a separate Act for medical devices as per global best practises, so that medical devices are regulated separately from pharmaceuticals.
  • Formulate an appropriate pricing policy for medical devices and re-examine it periodically  to ensure access to affordable devices for the population while also ensuring a sufficient return on investment.
  • Develop the National List of Essential Medical Devices along the lines of the National List of Essential Medicines to improve patient care, increase the affordability of tests, improve the regulation and quality of diagnostic tests, and promote the rational use of diagnostics.
  1. Strengthen health research capacity
  • Set up research consortia for diseases of high priority including neglected tropical diseases and emerging infections along the lines of the India TB Research and Development Corporation.
  • Identify at least 20 academic or research institutions at the regional level to act as hubs capable of training a minimum of 500 doctors every year.
  • Ensure the presence of at least one model rural health research unit in every state.
  • Cover the entire country with a network of viral research and diagnostic laboratories with a testing capacity of more than 15 lakh samples per year.
  • Identify key research areas in traditional medicine and facilitate collaborative research with modern systems of medicine.