New Delhi: The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana offers a unique opportunity to improve the health of hundreds of millions of Indians and eliminate a major source of poverty afflicting the nation. However, there is a need to address issues of accountability and governance in both public and private healthcare in order to meet the ambitious goal of universal health coverage (UHC) in India.
According to a new paper published online today in the journal PLoS Medicine entitled “The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance” authored jointly by academics from the George Institute for Global Health, National Health Mission of the Government of Himachal Pradesh and Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh here today, this ambitious policy and any progress towards UHC must be seen in light of the severe challenges facing the Indian health system. India is beset by deficiencies in the resources available to fund healthcare, the skilled workforce and infrastructure available to provide care, and oversight of healthcare provision.
The paper argues that private providers, being the dominant provider of care in India, need to be engaged at all levels for the successful implementation of the program but flags that the profit motive that drives the behaviour of these providers is a cause for concern. There is evidence from across low- and middle-income countries that private providers more frequently deviate from evidence-based practice, have poorer patient outcomes, and are more likely to provide unnecessary testing and treatment, and the data that do exist from India have mirrored these findings.
At the same time, public providers in India have been shown to face significant governance challenges as well, with services shown to be rife with absenteeism, of poor quality, and nonexistent in many areas of care. Corruption at all levels of the system from doctor training to investment decisions remains an issue.
The paper makes the case for fixing these deficiencies in order to achieve the stated goals in this ambitious scheme.
“The size and scope of the announced program present a huge opportunity to set India onto an optimal path to UHC. However, it can only be achieved by overcoming challenges of governance and accountability,” says Prof Vivekanand Jha, Executive Director of the George Institute for Global Health-India, one of the co-authors.
He added: “As new services are provided and coverage increased, successful implementation will require a parallel concerted push towards quality assurance, appropriate governance, and appropriate referral pathways in both public and private healthcare providers. There is a need to strengthen the stewardship function of the government to monitor the provision of care from private providers, who are key players in the Indian healthcare system. This could occur in a number of ways, such as through the development of robust referral pathways for patients, quality audits of providers, incentives to improve the efficiency and quality of care, strategic purchasing, and a general strengthening of the capacity of the public sector to effectively contract with and regulate the private sector.”
“AB-PMJAY represents an exceptional opportunity to overcome chronic shortcomings across the Indian health system and accelerate the nation towards universal coverage, improved health and stop the slide of tens of millions of Indians into medical-induced poverty each year. For this to happen, AB-PMJAY needs to be accompanied by a substantial injection of funding and widespread governance reforms to ensure the system uses its available resources to provide the care most beneficial to the Indian population,” added Stephen Jan from the George Institute for Global Health, Sydney.
AB-PMJAY, also called Modicare aims to build on existing schemes to provide publicly funded health insurance cover of up to 500,000 Indian rupees (over US$7,000) per family per year to about 100 million families (500 million people, 40% of India’s population). The scheme builds on other previous programs (The National Health Mission still forms the basis of primary care under the new program). The government has so far allocated 100 billion rupees (almost US$1.5 billion) to the program for 2018–2019 and 2019–2020. Currently, the country spends about US$64 per person on healthcare, two-thirds of which is privately financed by user fees.
Implementation and ongoing operation of the program needs to be carefully monitored to ensure that it is meeting its aims in a sustainable manner and negative unintended consequences are avoided.
Summary points from the paper
Public spending on healthcare in India is amongst the lowest in the world at just over 1% of GDP and the Indian health system is characterised by substantial shortcomings relating to workforce, infrastructure and the quality and availability of services.
The Ayushman Bharat National Health Protection Mission (AB-NHPM) approved by the Indian Government in March 2018 is an ambitious reform to the Indian health system that seeks to provide financial health protection for 500 million of the most vulnerable Indians, and halt the slide of the 50-60 million Indians who fall into poverty annually as a result of medical-related expenditure.
There is a need for wide reforms across public and private providers of care if India is to meet its stated aims of universal health coverage for its population. The success of the program will rely on a reformed and adequately resourced public sector to lead implementation, delivery and monitoring of the scheme.
While there are significant challenges facing the program, by providing the impetus for system-wide reform, AB-NHPM presents the nation with a chance to tackle long-term and embedded shortcomings in governance, quality control and stewardship and accelerate India’s progress towards stated goals of universal health coverage.