Unpacking Modicare – The evolving health care paradigm

‘Modicare’ health insurance schemepastedImage10

The recently launched Ayushman Bharat, also known as the National Health Protection Scheme (or even Modicare in popular parlance!) has two objectives — first, creating a network of health and wellness centers to bring all-inclusive primary healthcare close to the community, and secondly, providing insurance cover to 40 per cent of India’s population, that is most deprived, for secondary and tertiary care, including for instance, hospitalization costs. It was launched by the Prime Minister last month in Chhattisgarh and speaking on the occasion, he said that the Ayushman Bharat scheme is not limited to simply providing a service, but also invokes public participation so that we can create a healthy, capable and content New India,

Thus far, the country’s primary health care has been concentrating on reproductive, maternal health, newborn and child health as well as controlling certain communicable diseases. All this perhaps covers only 15% of the total health needs. Public health action for preventive/promotive health has also been limited and therefore there is a huge unmet need for primary health care, including care for non-communicable diseases (specifically, prevention and early detection and treatment of hypertension, diabetes, chronic obstructive lung disease, and common cancers), mental health, care of the aged, adolescent health, palliative health care as well as basic eye care and dental health.

The government has committed for two-thirds of resources to go into a comprehensive primary health care as part of the National Health Policy 2017. The model seems somewhat along the lines of the U.K. general practices health system but run largely by nurse practitioners and trained health workers, who are accessible near home. Healthy families, villages and cities is the goal of the primary health-care system. HWCs will help unleash a people’s movement for a healthy India.

The big change though is in how secondary and tertiary health care is sought to be delivered. Ayushman Bharat, popularly known as ‘Modicare’, is billed as the world’s largest government-funded healthcare scheme. The scheme in a way will override  many several Central Ministries and State/UT Governments schemes  meant for defined set of beneficiaries. To achieve improved efficiency, reach and coverage, there is a critical need to converge these schemes such as Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS). Now, in the new initiative, the government aims to cover over 100 million poor and vulnerable families (about 500 million beneficiaries) with up to Rs 5 lakh per family per year for secondary and tertiary care hospitalization. Beyond Primary care, everything else will be offered through the NHPS mechanism via public and empaneled private hospitals through a transparent mechanism. aiming to provide health cover of ₹5 lakh per family per year for hospitalization in secondary and tertiary care facilities.

When it takes off, given the ambitious size of the package, 40% of people, neonates to young and old, will have access to facility care for almost all the medical and surgical conditions that could occur in a lifetime. The programme will cover half a billion people and would align with what the State governments are doing already, with significant resources coming from the Centre. Many State governments would extend the benefits to additional beneficiaries through their own resources so that ultimately the population covered for catastrophic expenses could be two-thirds of India’s population, if not more. This mission enables increased access to in-patient health care for the poor and lower middle class. The access to health care is cashless and nationally portable. The Private hospitals who come on board will have to agree to terms such as package rates, adherence to standards and guidelines, ethical practice, respectful care and client satisfaction, and transparency. No matter, what the checks and balances, whether privatization of the health care at secondary and tertiary levels will keep costs affordable is something that remains to be seen.

The Modicare proposal which puts secondary and tertiary care in the hands of the private sector will primarily offer support for clinical services such as hospitalization. This will obviously not help fix the broken public health system in the country, which signs off after the wellness centers. Insurance companies are expected to play broker in ensuring fair costing. In the absence of a health regulator, it is not clear as to how this will play out.  The gravest issue remains the limited and skewed distribution of human resources at various levels of health services, with up to 40 per cent of health worker posts lying vacant in some states. Most primary health care centers suffer from perpetual shortage of staff and even district hospitals are without specialist doctors. The private sector will have to also deal with this challenge because India just does  not enough have trained human resources. The National Health Policy 2017 proposes “strategic purchasing” of services from secondary and tertiary hospitals for a fee so that people can go to both public and private healthcare providers for treatment.

The NHPM brings with it the opportunity to  target  a  population of 500 million, and in the process, bridge economic, gender and social divides  Seeing it one way, this health insurance scheme is a welcome development, particularly as insurance penetration in the country is so low. As of fiscal 2017, nearly 438 million persons were covered under various health insurance schemes, including 335 million under various government sponsored schemes including Rashtriya Swasthya Bima Yojana (RSBY). With the new scheme, the coverage will increase to more than 650 million persons.  However, the success of the programme will largely depend on ensuring that the services promised under the scheme are evidence-based, smoothly delivered and inclusive. The over dependence on the Private Sector to deliver services and the deliberate marginalization of the public sector as inept and inefficient and confining it to the parameters of a primary health center and wellness center does not augur well because if the public sector has been sloppy, the private sector has almost always been driven by profits and the nonprofit charitable sector is nearly extinct.

Shantanu Dutta is a former Air Force Officer and now a Development Worker for the last 25 years and more


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