By Kiran Mazumdar Shaw
A healthy India is a wealthy India. For an emerging economic superpower, health of its people is critical for economic productivity. Ayushman Bharat, which recently completed a year of existence, was conceptualised as an insurance based, healthcare delivery model that dovetails both preventive and curative healthcare at a coverage of Rs 5,00,000 per family per year.
Whilst preventive care is to be delivered through “health and wellness centres” that provide comprehensive primary care, curative intervention is sought to be addressed by leveraging existing public and private hospital infrastructure and human resources in the country. Universal health coverage (UHC) was launched via a fee for service model where government and empanelled private sector hospitals provide an opportunity to leverage a potential universe of general and ICU beds.
The government has also strategically linked primary and tertiary care via the National Health Authority to ensure better coordination across the continuum of care. The way forward is to build a digital healthcare architecture that leverages the power of technology to create Electronic Medical Records, Disease Registries, track real-time data capture and analyse health data to generate economic models for preventive and managed care.
It is also imperative that we transition from transactional records of patient episodes into longitudinal records aimed at driving operational efficiency. We must also direct health economic data to link value as opposed to cost with quality of care that will reward private sector providers that in turn will build a sustainable public-private relationship, which is so critical for tertiary care management within Ayushman Bharat.
Further, as we evolve our system, we must not forget the learnings from previous experiences of data collection by frontline ASHA workers, which met with several challenges. We must adopt innovative new technologies such as the use of voice-enabled records to build both ease and reliability of data capture which is emerging as a global best practice.
With India’s economic development, the burden of disease has shifted significantly from acute to chronic care. This shift has brought with it catastrophic health expenditures. There is evidence of large multigenerational debt accumulation for accessing medical care which was skewed towards the male gender. Ayushman Bharat is posed with a number of challenges that range from non-communicable diseases to women’s health and infant mortality.
The burden of chronic ailments such as diabetes, cancer, cardiac and respiratory disease is enormous. Women’s health is now a national priority. For example, breast and cervical cancer account for 40% of the cancer burden in India. What is also glaring is the insufficiency of current insurance schemes to offer protection to cancer patients, often driving families to extreme financial debt and even poverty. Cancer is undoubtedly the most expensive disease to diagnose and treat which necessitates a rethink on the insurance instrument. A carved out cancer insurance component is an option.
Diabetes and its associated comorbidities pose another big financial challenge to any proposed universal healthcare model. For example, the manifestation of diabetes in Chronic Kidney Disease leading to dialysis imposes a huge cost on the healthcare bill. As per the National Dialysis Programme Report 2016, an estimated 2.2 lakh new patients are added each year to access dialysis for renal replacement therapy resulting in demand of 3.4 crore dialysis every year. Annually this results in Rs 3-4 lakh expenditure for each patient suffering from End Stage Renal Disease (ESRD).
It is well-recognised that patient involvement in diabetes is critical. This is true for disease management in general. A reward mechanism, such as an incentive point system that can be ‘cashed’ in for additional overall tertiary care coverage for the family for better health management, is worthy of consideration.
Ayushman Points for Diabetes, as an example, may allow diabetics to accumulate points for better glycemic control, weight control, etc which in turn would lead to improved diet and exercise regimes thus delaying disease progression and thereby the costs associated with diabetes linked comorbidities. This approach of health incentives for early diagnoses and early intervention will further support the objective of the closed loop system.
It is also important to evaluate cost and efficacy of standard of care. For example, addressing the barriers to early insulinisation in the treatment of diabetes will improve outcomes and cost containment for this disease. The prescribing behaviour today veers towards a stack of oral pills rather than insulin. It is worth noting that the cost of the oral stack is 3X greater than the daily cost of insulin. There are many such examples of cost, efficacy and outcome that need to be studied and co-opted by Ayushman Bharat.
Finally, a successful transition towards a value-based healthcare system requires a shift in spending from curative to preventive. These resources will be required for programmes focussed on prevention such as encouraging screening for early detection of NCDs like cancer and diabetes. The skew between curative and preventive healthcare is typically 80% to 20%. Without zero-based budgeting, shifting this imbalance becomes a challenge. Alternative financing models that provide options for bridge financing to outcome investors, in this case governments, must focus on value based care to deliver financial sustainability.
Given its scale, the evolution of Ayushman Bharat is being closely watched globally. The success of this programme is critical to keep families protected from catastrophic health expenditures due to a growing incidence of chronic diseases. Let us celebrate the first anniversary of Ayushman Bharat with the hope that the 4.5 million families who have benefitted from this game changing health reform will pave the way for the world’s most technologically comprehensive UHC for the benefit of every citizen in India.
This article was first published in Times of India on 25th September 2019.