First, prepare

Where is the infrastructure for universal health care?

India may soon see the formal announcement of the Ayushman Bharat National Health Protection Mission, perhaps in Prime Minister Narendra Modi’s Independence Day speech. At least six states are prepared to roll out a pilot of the new health care scheme. Little, however, is known as yet about the details. While it was earlier assumed that it would be an insurance-based mechanism, it seems there will be greater state involvement in the administration of Ayushman Bharat, perhaps through a trust-based system or some hybrid private-public approach. Individual states are likely to take different views on the mechanism most appropriate for their particular circumstances. This will provide welcome flexibility in the initial stages, and allow for experimentation across different designs.

What is known, however, is that the scheme is likely to cover over 100 million poor and vulnerable families, providing coverage up to Rs 500,000 per family per year for secondary and tertiary care hospitalisation. It may be cashless for a significant proportion of the population, though recent beneficiary lists have not been prepared and this might be a controversial aspect of the scheme. There appears to be some haste in how the government is going about the announcement and roll-out of the scheme — not unrelated, perhaps, to the fact that universal health access was part of the ruling Bharatiya Janata Party’s manifesto promises in 2014, and now that the general election season is approaching swiftly, the party will be called to account by the electorate. However, while the intent to move quickly is to be appreciated, it is also important to note that a scheme with such a large scope, and one that will revolutionise a significant proportion of the national economy, cannot be properly implemented without adequate preparation. The experience with the GST roll-out should serve as a cautionary tale in this respect.

Two things are worth considering, therefore, in this context. A scheme focused on expanding access to tertiary health care cannot work without a significant preliminary effort to widen the supply of hospital beds, medical specialists, and so on. This has not so far occurred. There is a massive shortage in the supply of services — trained staff, hospitals and diagnostic centres, made worse by grossly inequitable availability between and within states. The deficit in doctors is particularly wide, with India being at least 75 per cent short of the number of qualified doctors it needs. It would be too sanguine to hope for a supply response after the scheme is introduced. That would cause an unplanned expansion and the associated bottlenecks and inefficiencies. Other countries, such as Thailand, that have created health care systems at India’s current level of development spent years in preparation. The government must lay out and explain how it intends to fill the infrastructure deficit alongside the phased roll-out of Ayushman Bharat. The second important fact is that a holistic approach to health care means that primary health care should be the actual focus of government effort and financing. That is where the greatest benefits are likely to accrue. Primary and community health care centres are understaffed, under-funded, under-trained and under-equipped. Questions must be asked about whether systemic reform in primary health care is not an essential first step towards the goal of universal health care. In spite of these two caveats, however, the government and Mr Modi deserve credit for seeking to put health at the centre of the policy agenda.