In his budget speech, the finance minister announced two big ticket initiatives in health — strengthening the country’s primary healthcare backbone through a network of 1.5 lakh health and wellness centres and providing an annual hospitalisation cover of ₹5 lakh for 10 crore poor families under the National Health Protection Scheme (NHPS).

It is rare that the most talked about announcements from a budget speech relate to the country’s health sector. This is a welcome and long-overdue change.

Comprehensive view

It is well known that India faces a dual burden of disease. Communicable diseases still account for a significant proportion of the disease burden alongside non-communicable diseases (NCDs) such as cancer and cardiovascular ailments. When expressed in terms of Disability Adjusted Life Years (DALYs), a measure of healthy years of life lost, communicable diseases account for 33 per cent of DALYs while 55 per cent are attributable to NCDs.

The battle against NCDs can only be won by early detection followed by prevention and promotion of a healthy lifestyle. A robust primary healthcare system is essential for achieving this because it is often the patient’s first point of contact with the health system. It is also true that a majority of illnesses can be tackled at the primary level before they become more complicated, expensive and challenging to treat. In fact, escalating costs make caring for patients in hospitals unsustainable. One of the best examples of wasteful spending is the US where a staggering 60 per cent of the total health expenditure goes towards 1 per cent of patients in tertiary hospitals.

Early warning

In India, the vision for primary healthcare was articulated as early as 1946 by the Bhore Committee. However, it has remained predominantly focused on reproductive and child health, including ensuring institutional deliveries. The need of the hour is for a much broader package of services to be provided, including early detection and referral of NCDs (cancer, heart disease, diabetes, hypertension, mental health disorders), geriatric and palliative care, emergency services as well as education on the use of safe water, toilets and menstrual hygiene management.

In this context, the budget announcement on health and wellness centres is a potentially transformational one. It is also aligned with the National Health Policy 2017 which envisages a comprehensive primary health system.

The proposed centres will be run by a team comprising of a mid-level provider (with a degree in nursing, AYUSH or community health and trained in primary care and public health), as well as frontline health workers like Auxiliary Nurse Midwives and ASHAs. These teams will provide preventive and promotive services to encourage the adoption of healthy behaviour. They will also partner with other frontline teams to ensure that the determinants of ill health such as nutrition, sanitation and education are addressed.

Moreover, being close to the community, the personnel at these centres will be well placed to engage with stakeholders such as panchayati raj institutions, religious leaders, local influencers and civil society to mobilise a mass movement for health.

National health insurance

Private Out-of-Pocket Spending (OOPS) at the point of care still contributes over 60 per cent of the total health expenditure in India. Worse still, the OOPS has been skewed towards the poorest two quintiles. As a result, catastrophic health expenditures are pushing roughly 60 million into poverty every year. This is estimated to increase poverty by approximately 3.6 per cent and 2.9 per cent in rural and urban areas respectively.

The proposed NHPS can be a game-changer for reducing the burden of catastrophic expenditure incurred on hospitalisation for millions. The scheme will be centrally sponsored, with a sharing of funds between the Centre and the States. Since it will take a few months for the precise mechanics to be worked out, a token but fairly substantial allocation has been made under the scheme for 2018-19. Of course, these allocations will also be boosted by the ₹11,000-crore revenue generated from the addition of a 1 per cent cess.

The scheme will undoubtedly pave the way for India to achieve Universal Health Coverage. However, given the variations across states, the current status of health programmes, the availability of resources, the rural-urban differentials and capacity for governance, it would be futile to strive for a uniform template for achieving UHC. The road to UHC would have to be flexible.

In Thailand, reforms were undertaken over a period of 30 years before the universal health policy was announced in 2002. Similarly, China experimented for nearly a decade before articulating its intention to implement UHC. What will work in the scheme’s favour is that it can leverage the lessons learned from the implementation of the Rashtriya Swasthya Bima Yojana and State-sponsored schemes like Yeshaswini and Aarogyasri.

Of course, the devil as always will lie in the implementation of these initiatives. However, the fact that such bold announcements were made in the budget signals the importance being accorded to health as a critical enabler for realising India’s much talked about demographic dividend.

The writers are with the Office of the Vice-Chairman, NITI Aayog. The views are personal