Indian urgently needs a system of sickness coverage that will prevent 60 million people falling in poverty due to sickness. We will never be able to reduce poverty drastically unless we protect people from financial cost of sickness.
This government has taken an unprecedented step in announcing Ayushman Bharat National Health Protection Mission (ABNHPM) - where government will cover about 40% of India population for sum assured of 5 lakhs per family. It is most welcome.
Let’s be clear that this is only an in-patient care coverage but “health protection”. This does not protect your health but pays for the cost of hospitalization. It is like car accident insurance – accident insurance cannot keep your car “protected”.
To protect health we need preventive actions like clean water and sanitation, clean air, mosquito control, stopping tobacco and alcohol and exercise etc. This is all public health which reduces the exposure to disease risks and prevents morbidity and mortality. But this is not covered by ABNHPM. It will need strengthening of programs public health programs.
To build a robust sickness insurance system we need four pillars. The first is good data on causes of death and disease profiles. We have very weak system of cause of death reporting and analysis. Some cities like London had better systems of cause of death analysis 300 years ago – called “Bills of Mortality”. It analyzed all deaths by cause, age and sex, printed the report and made public every week in London in mid 1600s!! No city or state in India is doing this today! Very few hospitals report indoor admission by cause and it is not analyzed. Good beginning has been made by state specific Burden of Disease estimate by ICMR and IHME published in the recent issue of The Lancet in 2017. We need to build on this with basic disease information system at state and national level which will include private sector. Without proper data on disease pattern no insurance can work efficiently. Our government statistical system has neglected health statistics very badly.
Secondly, for good health insurance we need to have standard procedures and prices which are developed based on reasonable calculations – if the prices offered are too low providers will avoid the scheme or cut corners where the patient will have to pay in terms of complications. In health sector we do not have a costing and pricing commission or any other mechanism at national or state level for costing of medical procedures. Some developed some pricing mechanisms for procedures but mostly they are ad hoc without detailed costing exercise. Karnataka is the exception where expert groups are formed and some costing work has been done for 25 common procedures which need to be scaled up to all 500+ procedures. Some state have arrived at a package rates by bidding and used the L1 prices. Countries like USA are using Diagnostic Related Group (DRG) based payments to reduce over supply of unneeded services.
As health services are locally produced and the cost of hospital infrastructure varies a lot from big city to small town, one standard price for the same procedure all over India will not work. So the insurance has to develop sliding scale based on level of city and may be level of experience the doctor. All these mechanism of price discovery and costing should be transparent and put on the government website. Over time we also need to fine tune the prices of procedures as per the new technology and demand supply dynamics. Once the prices are well set then government needs to manage the insurance companies or trusts well so that they promote the program and pay the hospitals in time.
Third is pillar for a social health insurance to succeed - we have to have a sense of equality. The world’s oldest social health insurance system is Germany’s sickness funds is built on key principle of “solidarity” and “equity”. In the German system, all workers and managers pay the same percent of their income in the fund and the fund pays to the doctors and hospitals based on treatment provided. Benefits are same to all citizens irrespective of class and socio-economic status – but they pay differently depending on their income. This may sound Utopian in Indian society as it is very hierarchical and class conscious. We hope ABNHPM program will help us move in this direction when the poor will get Rs 5, 00,000 coverage – which is exactly what I have through my personal contribution – which costs about 20 times more!! On being asked at a high level health meeting “How much health coverage should the poor have?” – my answer was “as much as the Prime minister has” – and that is the direction in which we are moving with ABNHPM. Identification of the poor and the BPL lists have been a big challenge hence a simple and transparent way to identify and enroll beneficiaries will be very critical to success of the program.
Lastly, insurance needs system to check fraud and monitor outcomes. If one patient’s fraud can earn 500,000 Rs then the temptation will be very high to attempt it. To prevent fraud, needs meticulously collected data, analysis and professionals who can monitor the program. Like ethical Hackers we need to hire some “ethical fraudsters” who will tell government how fraud can be done in the system and how that can it be prevented.
ABNHPM is a great opportunity for the poor to come out of poverty. So it should be seen and funded like a poverty alleviation program. It is the first step towards Universal Health Coverage in India. But we should not forget that next step for Universal Health Care is coverage of outpatient care which is currently missing from ABNHPM. Indian can be called a developed country without such social security system for health care.
The author is Director, Indian Institute of Public Health Gandhinagar, PHFI. The views expressed are personal.
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