What was perhaps the biggest announcement in the Budget didn’t actually involve any money. The National Health Protection Scheme, touted as the world’s largest healthcare programme, envisages providing medical insurance cover of up to ₹5 lakh each to 10 crore families. Assuming an average family size of five members, this translates to 50 crore people, or nearly 40% of the population.
This is a stupendous goal by any yardstick, and the first near-universal welfare measure in the health sector since possibly the 1980s, when governments, constrained by tightening resources and burgeoning populations, switched focus to targeting just the vulnerable sections of society, while leaving it to the private sector to take care of the rest.
And, as many have pointed out already, the Finance Minister did not allocate any money for this; he only promised to raise the resources when required.
A good idea?
I, for one, am willing to take Arun Jaitley at his word. I am willing to grant that when the time comes, North Block mandarins will pull some legerdemain and actually find the money to fund the share of the premium which the Centre will have to pay. Of course, if the contours of similar schemes in the past are any indication, this will still amount to only around 40% of the total required, with the balance to be funded by the States (health is a State subject, after all).
I am even willing to assume that the States too will fall in line and cough up the amount required, since aspirations have been already unleashed on this front and it will be difficult for any political party to swim against the tide and refuse to pay. So, assuming that the money is found and the insurance policies go live in a year or two, does this mean that a significant chunk of the population will be able to afford quality healthcare when they need it? Given the fact that out-of-pocket expenditure on healthcare is nearly 63% of the country’s total healthcare expenditure (one of the highest in the world — it’s 32% in China, 11% in the U.S. and the world average is 18.2%), and “catastrophic expenditure” on healthcare pushes millions back into poverty every year in India, an insurance scheme which provides up to a ₹5 lakh cover sounds like a great idea.
Or is it? There is one crucial difference between Medicare assistance (even of the Obamacare variety) and actual healthcare services. The former is a financial product which focuses on enabling beneficiaries to access existing healthcare facilities. It does not in itself ensure the creation of healthcare infrastructure — somebody will still have to build clinics/hospitals, staff them with doctors, nurses, medicines and equipment, and provide these at a cost which falls within the limits of the healthcare insurance policy.
The real challenge
This is where India has been slipping badly. For instance, it had only about 1,800 hospitals in rural areas, according to the government’s rural health statistics for 2017. The shortfall in percentage terms vis-à-vis the population (based on the 2011 Census) is 19% in terms of sub-centres, 22% in terms of primary health centres and 30% in terms of community health centres. As of March 2017, the number of buildings required to be constructed to meet requirements had crossed 40,000.
Worse, even if the buildings exist, they are often just that — shells, without the requisite staff. According to the Niti Aayog’s latest State-wise healthcare index, the proportion of vacant specialist positions (medicine, surgery, obstetrics and gynaecology, paediatrics, anaesthesia, ophthalmology, radiology, pathology, ear-nose-throat, dental, psychiatry) ranged from a low of 16.7% in Tamil Nadu (among the larger States clustering) to a staggering 77.7% in Chhattisgarh as of 2015-16. When it came to the availability of a doctor at primary health centres, even the best-performing States like Kerala and Tamil Nadu had 5.9% and 7.6% respectively, while over 41% of the primary health centres in West Bengal, Chhattisgarh and Jharkhand didn’t have a doctor available; this was 63.6% in Bihar. About half the primary and community health centres in Rajasthan, Haryana and Bihar did not even have a staff nurse; in Jharkhand it was 74.9%.
Given this dismal scenario, merely providing the amount is not enough. True, creating a potential addressable medical services consumer base worth ₹50 lakh crore will work as a tremendous incentive to the creation of such infrastructure in the private sector, but this will take time. Besides, the private sector will face the same challenges of getting trained medical professionals to work in remote and rural locations. It can, of course, pay more money to such people as incentive, but that again will push up costs.
The real challenge then remains unchanged: to create the physical healthcare infrastructure on the ground, equip it, staff it, and run it. The last is important. About a quarter of primary health centres in the country, for instance, do not have access to 24-hour power supply, and nearly a fifth don’t have water supply. After that comes the issue of meeting the costs.