Tuesday, September 25, 2018

Universal health coverage: As I understand it

Dr KK Aggarwal

Universal health coverage is the need of the hour. Two weeks back I was in Malaysia for the CMAAO Assembly, where the Malaysian Medical Association (MMA) spoke about their 40:40:20 scheme. The entire population of Malaysia has been divided into three income groups: Lower income group bracket 40%, middle income group bracket 40% and top 20 income bracket 20%. Their government has said that they would pay for and look after the lower 40% income group bracket.

That is what the Modi government has decided to do. 

Under Article 21 of the constitution of India, right to health is a fundamental right and under Article 467 state directive principles, it is the primary duty of the state government to provide this as per their means and if they cannot provide, they need to enlist the private health sector under PPP model.

Under Ayushman Bharat, the government is paying for the insurance premium of 50 crore people. Everybody has a criticism that the premium is too low for five lakh insurance. But the reality is it is not five lakh insurance, the insurance is of approximately one lac as the packages have been capped with the maximum cap being around one lakh for tertiary care procedures. For one lakh insurance, the premium calculation is correct. 

What is required is honesty at every level in running the scheme.

Being a capped reimbursement policy, chances of manipulations are lower except for billing one surgical procedure as two procedures. This loophole needs to be checked.

Once the government has divided the community into two segments the poor (under Ayushman Bharat) and non-poor (personal insurance), every hospital also can and invariably will have two categories in their establishments (general ward for Ayushman Bharat and private wards for others).

In my medical college, we were taught affordable health care under the subject low-cost healthcare and we all need to revise this topic. For example, why should I go for full hemogram in routine cases when the same information can be gathered by looking at the peripheral smear and ESR.

This scheme will promote the Make in India program of the Govt. Devices, consumables, drug, reagents and/or equipments will take precedence and their use will increase; we need to find out indigenous ways to manufacture these at low cost. Use of generics will increase, use of antiseptics may increase to cut down infection rates, which will bring down antimicrobial resistance (AMR).

The scheme will open doors for Jan Aushadhi drugs, only essential investigations, minimum cross referrals and promotion of day care procedures.  

Being a doctor means we are different and are considered demi Gods. Those who believe in it should do 10% subsidized charity by choice. The charitable rates can be reimbursed by the Ayushman Bharat schemes.

Universal health coverage is incomplete without disease prevention and harm reduction. The budgets for road safety, universal immunization, antenatal care, rural health, Swachh Bharat, environmental protection, skill development, drug development, safe water, safe soil etc. should be calculated as extension of health budget.

Harm reduction is already in the fray with elimination of mercury by 2020, sequential phasing out of Euro 4 vehicles with an aim to go for Euro 6, gradually reducing the air pollution parameters, phasing out trans fats in commercial restaurants.

A major mistake of the government is not banning tobacco from the country. The govt. is neither banning tobacco nor allowing comparatively safer electronic cigarettes in the market giving the message that conventional cigarettes are the best.

Among people who cannot afford, all those covered by ESIC, CGHS, Defence (BSF, CRPF, ITBP), PSUs, State health insurance, municipal corporations etc will automatically get excluded as they are already covered under respective schemes.  

Will casual or contractual laborers be covered under Ayushman Bharat? Another major challenge would be rare diseases.

Issues such as these will keep on coming up as the scheme is being implemented.

The success of the scheme will depend on the number of "no claims", amount of claims more than one lakh and percentage of disorders requiring recurrent hospitalization.  

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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