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PMJAY is crowding out money from equally vital programmes that decrease disease burden

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Even though Ayushman Bharat is a much-needed programme that enhances equity in society and promotes stability, there has been mixed experiences of various states during its implementation. Dr Harish Pillai, CEO, Metro Pacific Hospitals, Philippines explains to Viveka Roychowdhury how in the Asian context, some pointers can be taken from the model prevalent in Singapore and the ones envisaged to be rolled out in the Philippines

Dr Pillai, given your deep engagement with India’s healthcare system, what is your analysis of the effectiveness of India’s universal health coverage schemes so far?

The basic genesis of creating PMJAY- Ayushman Bharat as a flagship universal health insurance program was to encourage higher accessibility, improve affordability and provide a minimum level of assurance (quality) to all consumers. It was also modelled to be a safety net that protects the vulnerable masses from shifting towards acute poverty due to episodic encounters with private healthcare providers. Thus far the experiences of various states in rolling out the scheme tweaked to suit local models of existing care delivery services has been mixed. 

Unfortunately, the reimbursement rates envisaged in the programmes in several cases are below the threshold cost of care even though the guaranteed model of sustained case volumes is supposed to dilute the existing fixed cost burden. This reality has prevented large scale participation by major private chains thus impacting the overall success of the scheme. 

Another bug-bear is the lack of adequate healthcare infrastructure in the rural areas and the existing bias of concentration in urban areas is continuing. More needs to be done for viability gap funding to encourage private entrepreneurs to enter rural and semi-rural areas to create the required delivery mechanisms to close out the existing gaps.

There is another wholesome debate that states that the primary role of the state is to invest in good health policy, provide adequate funding, create infrastructure and promote wellness and preventive care. Due to constraints in the fiscal space, PMJAY is crowding out money from these equally vital programs that facilitate a decrease in the disease burden. However, in the overall context of India, Ayushman Bharat is a much-needed program that enhances equity in society and promotes stability.

What are the strengths which can be leveraged to tackle the gaps?

  • The tremendous data generated from the IT backbone should be leveraged for targeted district level interventions in tackling the burden of non-communicable diseases 
  • The PPP ecosystems should be encouraged at state levels by guaranteeing a predictable regulatory framework that will sustain interests and investments by private players 
  • Hybrid health integrated care provider networks can be encouraged based on models of prospective and capitated funds similar to a health maintenance organisation
  • Marketplace competition and leveraging technology stacks can be used to augment current scare resources 

Have schemes like Ayushman Bharat, PM-JAY addressed the existing inequities in India’s health care delivery model, like the lack of access to testing facilities, hospitals in rural areas, lack of funding, etc?

These central schemes have just made a tiny dent in the prevailing infrastructure landscape and more active and targeted fiscal interventions will be needed at state and district levels to address the existing inequities due to decades of non-action in this space.

The COVID-19 pandemic has disrupted and diverted funding and attention from many infectious diseases like TB as well as from routine immunisations. How are other countries with similar demographic and disease profiles addressing this problem?

Well for one, countries world over has realised the inadequacies of funding for the overall development of sustainable healthcare practices; we can also see an increasing trend in improving budgetary allocations towards healthcare. While management of the COVID-19 pandemic has severely stretched several economies, it is expected that a decrease in the COVID related burden due to the development of herd immunities will herald a shift towards proper funding of existing disease surveillance and intervention programs 

What are the learnings from other countries’ UHC systems you would suggest to India’s policymakers?

From an Asian context, two models worth studying are the ones prevalent in Singapore and the ones envisaged to be rolled out in the Philippines; both these nations seek to address the fundamental aspect of accessibility, affordability and assurance while the respective

architecture and execution differs. It is also true that the actual challenge is the size and complexity of India alongside the constitutional deference to the various states of the Union to develop their respective Visions. From the Philippines, the aspects of the model that could be considered are:

Creation of geography centric ‘Healthcare Provider Networks’ – HCPN in both the public and private space. Here the primary care network will act as a gatekeeper for the management of the health of its designated population and forms the basis of primary access for the required care. The referrals to higher centres of care based on case acuity models are based on the adoption of trigger points within the clinical practice guidelines. The acute care curative component is delivered by the different types of designated hospitals within the system all linked with an intelligent electronic medical record system. The highest complexity of care within a HCPN is provided by an ‘Apex’ hospital which is also responsible for the overall governance and management of the entire local network. It is envisaged that Primary care should be managed through a capitated fees model, the entire amount of which is prospectively given to the management team to handle. While the reimbursement for the curative component for hospitals within HCPNs will be based on pre-determined ‘Diagnosis-related groups- DRGs.  This movement away from case-based reimbursement towards DRG will bring about a lot of operational and cost efficiencies within the system. 

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