A nation’s development and growth is gauged by the health of its population. The fact that even after 70 years of independence, 80 per cent of the Indian population is not covered under any health insurance scheme and the average cost of in-patient treatment is almost half of their annual household expenditure is bound to mar its growth story.

Hence, announcement of the National Health Protection Scheme (NHPS) under the Ayushman Bharat Programme, in the Union Budget 2018-19, is timely and can be a trigger to achieving the country’s growth aspirations.

The government intended to achieve ‘Universal Health Cover’ at one go, but covering 1.3 billion population with the existing healthcare infrastructure and human resource is an impossible task. This prompted the government to settle at covering 40 per cent of the population — 50 crore people in the first phase. Described as “the world’s largest government-funded healthcare programme”, the sheer scale of this programme magnifies many its systemic challenges.

In terms of economic commitment, healthcare spends as a percentage of GDP across most nations that have achieved more than 80 per cent coverage of population is 5-12 per cent. For countries with large population, it takes 5-10 years to achieve 100 per cent coverage.

A FICCI-EY study in 2012 estimated that to implement UHC in India by 2022, the government would need to allocate health expenditure between 3.7-4.5 per cent of the GDP, as against 1.4 per cent in 2017-18. The bed-to-population ratio needs to be raised to 1.7 beds per 1,000 population from the current 0.9 beds. The required number of beds can be lowered with focus on primary care, as studies indicate that a one per cent increase in primary care usage can reduce hospitalisation rate by 0.03 per cent. The country needs another 9 lakh graduate doctors for primary care and around 1.2 lakh specialist doctors for secondary and tertiary care services.

The hospital business, particularly the multi-speciality tertiary care business, is capital-intensive with a long gestation period. Several of the current operating assets in India are not delivering the expected returns. More financing options along with incentives and tax benefits need to be provided to the private sector to aid development of healthcare infrastructure in Tier II and Tier III cities.

Ayushman Bharat is an extremely ambitious and complex programme and could be as challenging if not more than the implementation of GST or Aadhaar. Since health is a State subject and States are expected to contribute 40 per cent funding for the scheme, it will be critical to streamline and harmonise the existing State health insurance schemes and RSBY to NHPS.

The choice of purchasing model and empanelling providers would be critical to the success of NHPS. Countries with both public and private health infrastructure, such as France, Germany, China and Indonesia, have opted for dual mechanism — “provision by government and contract in from private providers”.

Trust deficit

India also follows a dual mechanism, however, there is immense confusion, dissatisfaction and trust deficit amongst all stakeholders as the healthcare scenario in the country is still evolving and is rife with lack of standard practices. There is a pressing need to evaluate and re-consider existing public health insurance schemes where private healthcare providers have been facing huge challenges, particularly due to improper procedure for empanelment and costing and inordinate delay in reimbursement to hospitals.

While a basic criterion exists for the empanelment of providers, mechanisms are yet to be developed to enable standardisation of service quality across provider categories. Although NABH accreditation ensures quality, only a small number of the hospitals are accredited. Considering the massive coverage of NHPS, the payers will have to widen their network of hospitals. Therefore, categorisation of hospitals into Entry level, Progressive level and Accreditation level — as specified by NABH — is necessary to overcome issues related to diversity of providers. In 2016, IRDAI notified ‘Entry Level’ as the minimum empanelment criteria for healthcare facilities by the insurance companies.

Reimbursement slabs should be objective, transparent and linked to accreditation according to the hospital categories. National Costing Guidelines and a standard costing template should be used for calculating reimbursement packages.

To improve clinical and operational efficiencies in the supply side, standardisation in clinical practice and other processes needs to be implemented through:

• Adoption of standard treatment guidelines, electronic health record standards, clinical audits etc. across public and private hospitals,

• Framing of referral protocols and implementing effective mechanisms for supervision leveraging technology. The Accountable Care Organization (ACO) model used in the US and other developed countries could be piloted in India to test the effectiveness for maintaining the continuum of care and,

• Integration of technology at each level of the healthcare continuum such as tele-medicine for remote locations, health call-centres, tele-radiology, app based emergency response etc.

Workforce woes

The limited health workforce available to deliver the promised services under Ayushman Bharat with its required outreach and effectiveness is a major concern. In addition to strengthening the number of healthcare professionals, we need focused skilling, re-skilling and up-skilling programmes for existing as well as additional workforce. Three key steps in this direction would be:

• Providing technical as well as soft skill training to Ayushman Mitras, with adequate incentives and provisions for periodic re-training and upgradation of skills,

• Making General Practitioners (GPs) responsible for overseeing the primary health network and and incentivising them to prevent the number of hospitalisations

• Introducing a nurse practitioner system in strict compliance with established clinical protocols, where they are authorised to handle several clinical responsibilities.

Successful medical claims management and processing is one of the most tedious tasks under any insurance programme. The key problems arisefrom lack of training among insurance agents, missing or inaccurate documentation and time consumed in resolving claim denials. NHPS must use biometric enrolment process, mobile and app based technologies for claim processes and payment wallets for real-time payments to streamline claim management. A robust fraud and abuse control mechanism should be implemented through use of digital technologies, business intelligence frameworks and standards for de-empanelment.

A Grievance Redressal Forum should be created to ensure timely resolution of complaints without intervention of civil or consumer courts. The government must encourage and recognise transparency, self-regulation and third party ratings and reward clinical outcomes to help bridge the widening trustdeficit in the sector.

The writer is Immediate Past President FICCI and Chairman Zydus Cadila- Cadila Healthcare Ltd

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