Ahead of 2014 Lok Sabha elections five years ago, both the Congress and the BJP, promised the people of India that they were entitled to the ‘Right to Health’. The Constitution of India guarantees this. Elaborate manifesto promises were made to improve the accessibility and quality of healthcare. Now, as this year’s polls approach, it is time to ask whether or not the government has delivered on its health agenda. While discussing the Modi Government’s biggest healthcare programme, Ayushman Bharat, as a part of our Health For Polls campaign, we have spoken to Dr Sanjiv Kumar, director of the Institute of Health Management Research and former executive director for the National Health System Resource Centre.
Ahead of the elections, how do you think the BJP measures up against its manifesto promises in 2014 for the health sector?
I looked at both Congress and BJP manifesto and created a matrix to map them. There was focus on health. But I also looked at other health-related determinants which fall outside the health sector like, water, sanitation, agriculture, air pollution etc.
Most of what was done by the present government was actually promised in the Congress manifesto as compared to the BJP Manifesto. Whatever was promised in both manifestos, it was rolled out, and some ambitious steps were taken like Pradhan Mantri Jan Aarogya Yojana, and that is good news. However, realisation of actual benefits will take a long time.
One of the components of Ayushman Bharat is Health and Wellness Centres. 1,50,000 SCs and Primary Health centres into Health and Wellness Centres. Although they were announced in 2016 Budget, only 8,000 have been converted. So, the progress of execution has been slow.
Why has the progress been slow for Health and Wellness Centres or expanding other health infrastructure in the country?
There are a couple of key factors for slow health infrastructure growth in the country. Firstly, there is a lack of skilled manpower in the health sector in India. Secondly, the area required for various functions to be performed at Health and Wellness Centres is much more compared to Primary Health centres and Composite Health Centres.
How would you review the government’s decision to become a healthcare payer from failing to be a healthcare provider?
Government is confused between being a provider and a payer. They want to promote private providers and be the payer in the tertiary healthcare sector. This is the idea behind National Health Protection Scheme. However, at the primary healthcare level, the government is a provider and is looking at Health and Wellness Centres as the only solution.
While the government is looking at private sector as the health provider, there has been criticism from the private sector itself over the insurance packages not being economically sustainable. What is your opinion on that?
There is no option but to involve the private sector for providing tertiary healthcare because the government hasn’t expanded the public sector hospitals. One issue which comes up is what payment should one give to the private sector for services/products. Hence, the government has been fixing prices of products and services. However, sooner than later the government needs to look at a method of price regulation so that a balance is maintained between ensuring quality of healthcare and ensuring economic sustainability for the private players. Otherwise, the private players will recoup the money from those who are not insured under the health insurance schemes and the prices of accessing healthcare would rise up drastically.
Talking about Ayushman Bharat, the government has based its argument on a Bill and Melinda Gates Foundation study, which pitches for wider access to healthcare. A contradictory Lancet study suggests Indians die due to poor quality of healthcare. How can we aim to strike a balance?
We can learn lessons from Immunization programme in India. Both quality and access have to go hand in hand.
The Interim Budget saw an increase in funds for Ayushman Bharat to Rs 6,400 crore. This marks an increase of Rs. 4,400 crore from last year’s budget for the scheme – and a 220 percent per cent rise in the allocation. How do you perceive this move?
It is important to understand that there is an allocation of Rs. 5 lakh cover as health insurance. However, the money spent as the premium is much lesser. In my experience, the government has been able to cater to the beneficiaries that have approached the hospitals for seeking health services. The government has promised that the budget would be increased further if required.
However, the issue of accessibility and quality need measures beyond budget allocations. Especially, the issue of quality of healthcare in India is one major issue. The government launched the National Quality Assurance Programme which has been under implementation for 5 years now but the progress has been extremely slow.
Do you think the increased allocation of budgets would ensure a higher quality of healthcare? How would you define the state of healthcare in India and do you think the government is investing enough to improve the current standards of healthcare?
It is important to keep two aspects in mind: allocation of budgets and absorption capacity of the health systems. While our budget allocation is abysmal compared to many countries in the world, even the budget allocated in our country is not completely used.
The system needs to be supportive in order to ensure complete use of budgets. However, corruption and lack of skilled manpower cause syphoning off inadequate use of funds.
Another issue ailing the utilization of budgets is that the government at the Centre and the State releases funds only towards the end of the quarter and the departments are left with very little time to utilise the budgets. Same issues occur at the State level as well. As a result, utilisation gets delayed.
Even as Ayushman Bharat has seen an enrolment of over a million Indians, it is facing several challenges like lack of funds and infrastructure. Do you think it is a big reform that will improve healthcare in India?
Ayushman Bharat is not the whole and sole solution to health comprehensive. External Determinants of health aren’t covered under Ayushman Bharat. Preventive care isn’t a part of Ayushman Bharat. Although the present government is working on sanitation and clean cooking gas, but these are sporadic efforts. There is need for comprehensive efforts from any government which looks at the continuum of health. Out-patient care is missing from Ayushman Bharat package. While it is proposed that Health and Wellness Centres will take care of this aspect. But the question is that the number of Health and Wellness Centres are limited in the country and isn’t sufficient to cater to the population of the country. Even in rural areas, two third people go to private facilities. Out-patient care at primary level is also ignored. Additionally, as the disease burden is shifting towards NCDs, Outpatient care is a solution and needs to be covered under any health scheme.