The Long-awaited Bridge
Ayushman Bharat – the answer to bridge the health divide between the rich who have access to world class healthcare & those who are deprived of such access
By: Swami Swaminathan
At last. Ayushman Bharat. The answer to bridge the health divide between the rich who have access to world class healthcare and those who are deprived of such access. Indian citizens at the bottom most part of the pyramid are now increasingly aware (thanks to the communication revolution) that for most diseases there is cure but it is just that they are deprived of access to quality healthcare. A real feeling of deprivation which if not managed effectively could have huge social consequences in the very near future. It was sweet music to ears when the Hon'ble Prime Minister of India from the ramparts of Redfort on the occasion of the 72nd Independence Day said that when "125 crore people move towards achieving a goal, there is nothing that cannot happen". It is even more heartening to see that the policy makers have now realised that "you cannot have people move unless people are fit enough to move". It is better now than never for the powers to realise that "unless you have a healthy India there can be no wealthy India".
When we are told that there is no predetermined budget and the governments will keep providing funds based on the claims received, this seems very idealistic and just does not sound professional
Putting India on the global map
The Prime Minister announced the launch of the Pradhanmantri Jan Arogya Abhiyan so that the poor & the common man gets free treatment for serious diseases and can be admitted to big hospitals free of cost. The Pradhanmantri Jan Arogya Abhiyan and Ayshman Bharat Yojna we are told will cover 10 crore families of the country. We are told about the provision of giving Rs. 5 lakh per annum health insurance for each family. It means about 50 crore citizens belonging to 10 crore families will benefit. This clearly is a great initiative billed as the world's largest health insurance scheme. The Hon'ble Prime Minister reiterated that in just about a month from the implementation launch (23rd of September), it will be launched throughout the country, no poor person of the country will have to face difficulties in dealing with diseases. The nearly 5 crore people who get pushed below the poverty line each year due to health care costs will be a curse of the past. He has promised that no family will be destroyed due to healthcare. He has said that new hospitals will be built in Tier 2 and Tier 3 cities. There are 50 crore citizens at the bottom of the pyramid whose expectations have been raised sky high. Most of them now believe that their misery around healthcare will all fly away and that they will have access to quality and free healthcare both in private & public hospitals.
The stage has been set
How does the environment on the ground that has to make all this happen stack up in the backdrop of the huge expectations that have now been set? 1. Many states for strategic & political reasons are opting to set up their own subsidy pools to fund the scheme. And what is the outlay required is anyone's guess. There is a very high possibility of these subsidy pools running out of funds from time to time and there are very high possibilities of mismanagement, fund leakage, frauds and delays in settlement unless high levels of process robustness supported by technology are deployed to track end to end of administration of this scheme. While we will all hope for the best, we are all once bitten twice shy. 2. When we are told that there is no predetermined budget and the governments will keep providing funds based on the claims received, this seems very idealistic and just does not sound professional. We will all hope for the Magic Genie to do its bit. 3. Given that the private sector healthcare provides about 75% of outpatient care and 60% of inpatient care we are told that the government is banking on the public-private partnership (PPP) model. We are told that there is a need raise an additional 160,000 hospital beds to provide health cover under this Ayushman Bharat-National Health Protection Mission (AB-NHPM). Yes, private healthcare institutions have the wherewithal to effectively deal with most heath care situations and in most cases can deliver quality healthcare efficiently. But private healthcare providers are no compassionate capitalists. These providers many of whom are backed by private equity players &/or private financing sources have (and achieve) extraordinary expectations of returns. Added to this, is the obscene real estate costs in most cities and towns, which means very high capital investments including state-of-the-art medical equipment etc. And given the scarcity of quality human resources, the age-old economic theory of supply vs. demand plays out driving costs & prices higher & higher. It is no wonder we are being told, given the single-minded commercial expectations of the private institutions, the scheme in its present form, may not encourage private hospitals to wholeheartedly support the initiative. A very innovative thinking and a model, which will facilitate private sector providers to move into Tier 2 & Tier 3 cities and build cost efficient and world class delivery institutions will be the key to the success of the scheme. It has to be a trusted partnership between the governments and the private sector, which is many cases is completely lacking. Unless this trust develops and the private sector treats healthcare as a sector, which requires a humane touch as against a luxury industry outlook and money-making machine, "Health for All" will continue to be a dream for a very long time. This will be counterproductive and detrimental to the interests of the people at the bottom of the pyramid to whom this scheme is mainly intended. 4. The one other key stakeholder in all of this is the insurance industry. With the end objective of keeping costs down and eliminating intermediaries, we understand many states will implement this scheme through a trust model or a mixture of trust and private insurances. While insurance companies will clearly see this as a big loss of opportunity of incomes, growth and valuations, only time will tell how far the trusts can keep the scheme sustainable. Again, there is a clear & immediate need for a trusted partnership to develop between the governments and the insurance industry. Clearly it is not sensible to lose out on the expertise, domain intensity, technology backbone that most insurance companies have built and have access to. Reinventing the wheel by the government is not a good idea. Again here, the insurance companies will need to see a larger purpose beyond just profits and valuations. Profits will have to be made from volumes at the bottom of the pyramid and smart management of risks. 5. It should not be lost on any of us that massive infrastructure on all fronts will need to be created to support this ambitious program. Having said this, there is an immediate need to sweat assets already created across the healthcare chain be it in the private or in the government sector. Given the demand for healthcare far outstripping supply, the need for being highly-productive and cost efficient is not in the survival kit of most healthcare institutions be it in the private or public sector. If it was so, how does one explain thousands of healthcare delivery institutions across the country have less than 50% utilisation of assets already created. How does one explain the crores of rupees of advertising that healthcare institutions spend seeking footfalls each year. Paradoxical it sure is. There is an urgent and immediate need to sweat assets already created to the hilt, improve productivity and reduce costs of delivering health care. Many institutions presently leave a lot of money on the table, which pushes up costs of healthcare and therefore pricing. This clearly is not a catalyst for change, which Ayushman Bharat seeks to deliver. 6. There is an immediate need to convert all healthcare delivery institutions in the country to smart healthcare clinics & hospitals. This will require the combination of technology and human workforce to create institutions, which will be future ready always. We are already in the cusp of a huge transformation based on cyber & physical systems. This includes Internet of Things, cloud computing, robotics, artificial intelligence, 3D printing and so on. Tech-driven healthcare has to be a must without exception. The optimisation and automation of processes, built on an ecosystem of interrelated resources, is needed for better & cost-effective patient care. Remote monitoring solutions will have to make way for virtual diagnoses, where doctors can diagnose patients without actual visits. This will be a breakthrough in tier II and tier III cities where access to proper healthcare is a problem as 60% of hospitals and 80% of doctors in India are in urban areas. Smart healthcare professionals will have to adopt processes with tools such as AI-enabled predictive algorithms that can determine the possibility of a disease even before the occurrence of the first symptom. Clearly, Ayushman Bharat will need to succeed. It just cannot be the responsibility of only the government to make it happen. Each and every stakeholder in this journey will need to put their best foot forward. For all the stakeholders, it has to be a higher calling than seeing this as yet another business opportunity. And finally, as John F Kennedy said "…look to the future not just to be a part of it, but to shape it…"