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In August 2014, The Lancet – perhaps the world’s best-known medical journal – had published “An Open Letter for the People of Gaza,” criticizing Israel in the wake of the 2014 Gaza conflict.
Richard Horton, the editor-in-chief of the journal since 1995, had taken a lot of heat, with Sir Mark Pepys, ex-Head of Medicine at University College London saying, “Horton’s behaviour in this case is consistent with his longstanding and wholly inappropriate use of The Lancet as a vehicle for his own extreme political views.
It has greatly detracted from the former high standing of the journal.” Richard Horton had responded then with a telling rebuttal: “How can you separate politics and health? The two go hand-in-hand.” Horton, it appears, truly stands by that line, as he has inserted his fingers into the most bountiful political pie of all – the Indian General Elections.
In an editorial Comment on the Lancet, published on the 11th of September, the editor of a medical journal – journals whose editorial slants strive hard to be non-partisan, and indeed, are expected to be thus – appears to have done what could be considered egregious: he has written a stump speech for PM Modi ahead of 2019, saying Modi is the first prime minister of India to have prioritised universal health coverage as part of his political platform under the 'Ayushman Bharat' programme.
His editorial went on to say that Rahul Gandhi has yet to match the prime minister’s “Modicare” in terms of his own party’s health offerings to the people of India. This political opinion in a medical journal is the subject of our Story of the Day.
What did The Lancet say?
“Health should be an important issue in India's coming general election,” says Horton in his comment, and yes, we agree that it ought to be. But soon after that, also launches into the specifics of a programme that has not been launched yet. September 25 is the launch date of the Ayushman Bharat, a National Health Protection Mission (AB-NHPM). The government has lofty plans under this scheme. The website for the programme claims:
“Ayushman Bharat – National Health Protection Mission (AB-NHPM) will provide financial protection (Swasthya Suraksha) to 10.74 crore poor, deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data (approx. 50 crore beneficiaries). It will offer a benefit cover of Rs. 5,00,000 per family per year (on a family floater basis).
AB-NHPM will cover medical and hospitalization expenses for almost all secondary care and most of tertiary care procedures. AB-NHPM has defined 1,350 medical packages covering surgery, medical and day care treatments including medicines, diagnostics and transport.
To ensure that nobody is left out (especially girl child, women, children and elderly), there will be no cap on family size and age in the Mission. The scheme will be cashless & paperless at public hospitals and empanelled private hospitals. The beneficiaries will not be required to pay any charges for the hospitalization expenses. The benefit also includes pre and post-hospitalization expenses. The scheme is entitlement based, the beneficiary is decided on the basis of family being figured in SECC database. When fully implemented, the AB-NHPM will become the world’s largest government funded health protection mission.”
Richard Horton said the prime minister has grasped the importance of health not only as a natural right of citizens, but also as a political instrument to meet the growing expectations of the emerging middle class of India, which is engulfed in a "swirling epidemic of non-communicable diseases".
To make his case – a rightful one – that India is indeed engulfing in a swirling epidemic of non-communicable diseases, he listed five Lancet papers which paint a rather damning picture of India’s health status.
- Ischaemic heart disease is the leading individual cause of disease burden in India. The contribution of cardiovascular diseases to total deaths has almost doubled since 1990.
- The number of Indians living with diabetes has grown from 26 million in 1990 to 65 million in 2016.
- The incidence of all cancers increased by 28 percent between 1990 and 2016, with new cases of cancer reaching 1·1 million.
- Those who suffer with chronic obstructive pulmonary disease have risen from 28 million (1990) to 55 million (2016).
- And while India is engulfed in this swirling epidemic of non-communicable diseases, the country is also in the grip of a mental health emergency. India could claim 18 percent of the world's population in 2016, yet it accounted for 37percent of global suicide deaths among women and 24 percent among men. The death rates from suicide in India were 2·1 times higher among women and 1·4 times higher among men than global averages in 2016. Suicide is the leading cause of death among 15–39-year-olds.
Real numbers; terrible crisis.
But it was another usage of the word “crisis” that Horton latched on to, to make his point. Referring to Gandhi's statement of “There is a full-blown crisis in India” at the London School of Economics last month, The Lancet editor-in-chief said the Congress president was referring to a "job crisis", but the five papers published across three Lancet specialty journals have revealed that there was also a "health crisis" in India.
Horton went on to add, “Rahul Gandhi has spoken about a “modernising impulse” in India and the possibility of “a transformation of 1·3 billion people”. Modi has grasped the importance of health not only as a natural right for India's citizens, but also as a political instrument to meet the growing expectations of India's emerging middle class.
Modi is the first Indian Prime Minister to prioritize universal health coverage as part of his political platform. Rahul Gandhi, despite his promises to help lower castes, tribal communities, and the rural poor, has yet to match Modicare. There is now every prospect that as the BJP and Congress set out competing and contrasting visions for India's future, health will rightly become a decisive issue in next year's general election.”
Horton in the article, said Modi's stated goal is to build a new India by 2022. Listing pretty much all the stated objectives of the government as seen on the website, Horton went on to add, “Together, these twin programmes should improve access to quality health services and reduce out-of-pocket health expenditures,” it said.
Horton went on to further extol the virtues of Mr Modi and his yet-to-be-launched programme: “After years of neglect, the Indian Government has at last recognised the perils of public discontent about health.”
While we are at it, what is the status of NHPM?
A large part of the success of NHPM – termed the world’s largest health insurance scheme – hinges on the participation of the private sector. The private sector does provide about 75 percent of outpatient care and 60 percent of inpatient care in all of the country.
Even before the announcement of the scheme, the government has been exhorting the private sector to increase its participation in more public-private partnerships (PPP). Mint said, “In 2017, the government think tank NITI Aayog proposed that the ministry of health and family welfare adopt the PPP model to provide diagnosis and treatment for major non-communicable diseases in smaller cities. The majority of patients prefer the private sector over the public sector for healthcare services. According to the Economic Survey 2018, the expenditure by the government healthcare providers accounted for only 23 percent of the current health expenditure.”
The PPP model has been tried out in a few states. Odisha, Andhra Pradesh and Uttarakhand attempted to use the PPP framework to set up secondary and tertiary care facilities. Uttar Pradesh has also recently announced that it will establish more than 1,000 hospitals under the PPP model. The Haryana government, in July, entered into a PPP agreement with the Kerala-based Meditrina Group of hospitals for cardiac care. So, private sector participation is key to the success of the scheme, and therein lies the rub.
“Not even 1 percent of the private hospitals expected to be empanelled to provide services under the Ayushman Bharat-National Health Protection Mission (AB-NHPM) carry a quality tag,” says Mint. The health protection mission aims to cover more than 100 million poor and vulnerable families for secondary and tertiary care hospitalization in India where more than 70 percent of all health services are provided by the private sector.
According to a PwC-CII report, at least 160,000 more hospital beds are required for the implementation of the scheme as the government intends it. As of now at least 6000 private hospitals are likely to join the AB-NHPM but not all of them may meet the eligibility criteria for what may be considered “quality care,” as not all of them may be accredited by the National Accreditation Board for Hospitals and Healthcare Providers (NABH), according to Quality Council of India, which is an autonomous body aimed at ensuring that standards are maintained in various sectors including the health sector. NABH evaluates healthcare providing organisations through rigorous self- and external evaluations.
Harish Nadkarni, CEO of NABH said to Mint, ““Currently, we have around 540 NABH-accredited hospitals in India which is a very small number. All these hospitals may not join Ayushman Bharat. NABH accreditation indicates that a hospital has best-in-class services and gives hospitals additional benefit as these hospitals will get more in the base rate in the scheme as compared to the non-accredited ones. It is totally a commercial decision and a private hospitals’ discretion to join or not to join the government scheme.”
The government has spun its acchhe din weave on this issue as well, with Alok Saxena, joint secretary, ministry of health and family welfare, hoping that things would change considering the incentive carrots that are being dangled. He said, “More and more NABH-accredited hospitals should join Ayushman Bharat because of the incentives. NABH-accredited hospitals will be paid 15 percent higher rate and entry level NABH hospitals will be paid 10 percent higher for the same package than non-accredited ones.”
The programme is still in its nascent stages. “At least 29 states and Union territories have started working on the implementation of the scheme,” according to the Union health ministry. Pilot projects have been started in 16 Union territories, while other states will launch pilot projects before the launch of the scheme this month, on the 25th, the birth anniversary of Bharatiya Jana Sangh leader Deendayal Upadhyaya.
Saxena went on to explain, “We will try to ensure that we provide quality healthcare through private hospitals. Getting entry level accreditation from NABH is not very difficult and there should be around 2,000 entry-level NABH hospitals, which is low.
It is the just the starting of the scheme. If not immediately, gradually the quality healthcare systems under Ayushman Bharat will fall in place. We are empanelling hospitals according to their specialty and super-specialty such as cardio, neuro and nephro. Even before empanelment, the government will do reality checks of the hospitals if they have the required equipment and tools to provide quality healthcare.”
But quality healthcare and still-reluctant participation from the private sector are hardly the only challenges that the scheme faces. The scaling up from the existing Rashtriya Swaasthya Bima Yojana (RSBY) to the NHPM is the educational equivalent of applying for a Masters in astrophysics right after UKG.
RSBY had a coverage of 30,000 rupees while NHPM has 5 lakhs; RSBY offered limited services while NHPM offers high-end procedures too (many of which are largely available only in private sector hospitals); the premium for RSBY was Rs 300 to Rs 400 while we still do not know what the premium for NHPM will be; RSBY insured a total population of 18 crore people, whereas NHPM hopes to insure nearly thrice as many, at 50 crores!
The government will foot about 22 percent of the overall financing of the programme (with 60:40 centre-state split), while about 67 percent is going to be from household out of pocket expenditure. About 11 percent will come from local bodies and other schemes and private insurance.
Analysts have noted many foreseeable challenges – enrollment of ghost beneficiaries; impersonation; doctors performing procedures not required; unnecessary conversion of OPD patients as inpatients, thus taxing an already taxed healthcare system which, in many cases, has neither the infrastructure nor the personnel support; unscrupulous hospitals charging fees even though the scheme is cashless; and of course the lack of education among the people insured under the scheme about what they are eligible for and what not and how they can prevent being taken for a ride.
These are not small challenges. There needs to be greater clarity about how the scheme will run, and achieve what it hopes to – a happier, healthier India.
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