How to nudge India’s public health infrastructure?

Syllabus: GS2/ Health, Government Policies & Interventions, Issues Arising out of their Design & Implementation

In Context

• A recently released private report claims of ‘Bypassing Ayushman Bharat & deceiving poor patients in Delhi’s Safdarjung Hospital’.

Health Sector in India

• Healthcare has become one of India’s largest sectors, both in terms of revenue and employment. 
• The Indian healthcare sector is growing at a brisk pace due to its strengthening coverage, services and increasing expenditure by public as well private players.
• India’s healthcare delivery system is categorised into two major components public and private. 
  • The government, i.e. public healthcare system, comprises limited secondary and tertiary care institutions in key cities and focuses on providing basic healthcare facilities in the form of primary healthcare centres (PHCs) in rural areas. 
  • The private sector provides a majority of secondary, tertiary, and quaternary care institutions with major concentration in metros and tier-I and tier-II cities.

The report highlights

• The report highlights two facts about the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. 
  • It highlights the key role of the treating doctor in deciding the type of medical package to be booked for a patient, and whether a patient will be registered under a PMJAY package at all. 
  • The report reveals how a doctor can mislead the patient on the premise that “Ayushman Bharat Clearance would take months.”
• Contrary to popular perception, the time taken to settle claims in public facilities was not unduly high. 
  • Of the claims registered across all facilities, 54 percent were settled. The average time taken for settlement of these claims was about 21 days.
• There were indications of a lack of active interest in the scheme by the medical team in public facilities.

Pradhan Mantri Jan Arogya Yojna (PM-JAY)

• About:
  • The scheme was launched in September 2018 and recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC).
  • It is a Centrally Sponsored Scheme having a central sector component under Ayushman Bharat Mission.
• Aims and Objectives:
  • To accelerate health system preparedness for immediate responsiveness for early prevention, detection and management, with a focus on health infrastructure development including for Paediatric Care and with measurable outcomes.
• Key Features: 
  • It is the world’s largest health insurance/ assurance scheme fully financed by the government and the cost of implementation is shared between the Central and State Governments.
  • It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India.
  • It covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses such as diagnostics and medicines.
  • There is no restriction on the family size, age or gender.
  • The RSBY had a family cap of five members. 
  • All pre-existing conditions are covered from day one.
• Eligibility: 
  • The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. 
  • The coverage mentioned under PM-JAY, therefore, also includes families that were covered in RSBY but are not present in the SECC 2011 database. 
• Benefits:
  • It provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
  • It envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year.

Challenges

• A host of factors within a public facility contribute to this lack of active interest by the medical team in the scheme. 

• Inadequate incentives for doctors:
  • As per the guidelines of the National Health Authority (NHA), a percentage share of the claim revenues transferred by the state health agency to public facilities is to be distributed among the medical personnel as staff incentives. 
  • This share could vary across states. Consequently, a treating doctor also receives a financial incentive. 
  • Yet, it may not incentivise a doctor adequately to register a patient in the scheme. 
• Inadequate incentives for Arogyamitra:
  • With relatively modest physical infrastructure and human resources, the medical team was often stretched with clinical activities. 
  • The only supporting staff for the scheme was an Arogyamitra, whose responsibility was to register patients under an appropriate package in consultation with the treating doctor. 
  • Arogyamitra’s remuneration was linked to the number of cases he can successfully register under the scheme (pre-authorisations), and not to the final settlement of claims. 
  • As a result, the Arogyamitra had little incentive to follow-up the claims with the required documentation at subsequent stages and ensure settlement.
• Vested interests:
  • The ignorance of the poor and the information asymmetry between doctors and patients creates a fertile ground for denying benefits to the poor to serve vested interests. 
  • District-level aggregate figures indicated that the proportion of claims settled in public facilities was significantly lower than their private counterparts.

Suggestions

• Improving incentive structure:
  • Addressing the incentive structure and operational dynamics of the scheme within public facilities can unleash the full potential of the scheme. 
• Need of active interests:
  • An active interest in the scheme by public facilities can ensure a substantial volume of additional revenues, which could then be utilised for infrastructure development and establishment of better amenities setting in a virtuous cycle. 
• Improving infrastructure:
  • The improved infrastructure could enhance the facilities’ potential to cater to more packages and ultimately improve health coverage for the poor.
  • This is in addition to ensuring that no poor person is excluded due to database errors in eligibility. 
• Role of governments:
  • Besides, state governments must play a complementary role by providing adequate manpower and enforcing accountability to ensure a higher volume of services in public facilities.

Way ahead

• The health (and education) of Indians is the most important determinant of what the country can achieve during the next 25 years of Amrit Kaal. 
• We must find ways to both find more money for health, and also more health for the money to ensure that all Indians achieve their true potential.