Is hospital care getting prioritised over primary healthcare in India?

With the Union Cabinet giving its nod to the recently announced National Health Protection Scheme (NHPS) — aimed at protecting 100 million poor and vulnerable families against hospitalisation expenses — some design elements of the scheme are known now. For example, the scheme will cover all pre-existing diseases, will allow for portability of insurance cover, and will also cover pre-hospitalisation and post-hospitalisation expenses to some extent. These are all sound design elements.

However, the fundamental question that many experts/policy observers are asking is: is the Indian government giving higher priority to the hospital care at the expense of the primary care?

Although the finance minister, in his Budget speech, mentioned both the components of Ayushman Bharat viz, NHPS as well as health and wellness centres (HWCs), what is hogging the limelight is NHPS. For the primary healthcare, the government aims at converting 150,000 health sub-centres that currently provide selective primary care into HWCs that would provide preventive and promotive public health services as well as comprehensive primary care.

While the public investment in the hospital care provides financial protection against hospitalisation costs, investment in primary care improves health outcomes. One investment is somewhat concentrated while the other investment is broad-based, often spanning different sectors. One deals with passively treating patients that show up in hospitals while the other deals with empowering people to take charge of their own health and go for early detection and management of disease risk factors. One could guzzle endless resources while the other not only makes limited demand on resources but also adds good value to public investments in health.

Going by the Budget allocations for 2018-19, both the interventions have received tiny allocations. But their potential need for funding are huge. Both these interventions are to be co-financed by states and implemented solely by states with or without the technical assistance from the Centre.

The government seems to have prioritised both these tracks as it is simultaneously working on both fronts. However, the hospital care track will move faster than the primary care track for some good reasons. One, the accumulated experience of states in implementing Rashtriya Swasthya Bima Yojana — a scaled-down version of the proposed NHPS — will come handy in rolling out whatever NHPS model they choose to adopt. Two, fixing the hospital care piece requires dealing with fewer entities than fixing the primary care piece which will require dealing with over 700 district administrations for converting 150,000 health sub-centres into HWCs. Third, lack of prior experience of states/districts in operating HWCs will mean slower pace of movement on the primary care front. In all likelihood, the primary care track will lag considerably behind the hospital track.

Thailand: A role model
Ideally, a strong primary healthcare system must precede any financial protection intervention at scale for hospitalisation costs. This is so because a robust primary healthcare with appropriate referral system constitutes the key strategy for overall systems efficiency and better quality. At the very least, the two tracks need to progress hand-in-hand.

If one looks at the experience of Thailand — a country often cited to be an excellent example of how any developing could achieve the universal health coverage (UHC) — it made a conscious decision to invest heavily in its rural health infrastructure before rapidly covering its 18.5 million uninsured population in the early 2000. Further, Thailand continued strengthening its primary healthcare well beyond its attainment of UHC. As a result, outpatient visits to rural health centres increased steadily overtime. Of the total out-patient visits, share of visits to rural health centres increased from 29 per cent in 1977 to 38 per cent in 1987 to 52 per cent in 2000, and to 78 per cent in 2010. This would not have been possible without huge public investments in primary healthcare.

Is India sequencing it wrong?
As the saying goes, there is no such thing as right or wrong; there are only consequences. Nowhere is this saying more applicable than in the development sector where progress often happens in a zig-zag manner, that is, progress in one area creates pulls and pressures which in turn produce tension that forces progress in other areas as well.

A well-funded and a well-run primary healthcare system with HWCs as its lowest tier, is a long-drawn process requiring a long-term strategy and a continuous effort. In the meantime, the financial protection intervention for hospital care will not wait that long and will progress much faster than primary care intervention. As a consequence, there will be greater equity for those poor households who need the hospital cover in the near future but reaping of the efficiency gains that are generally associated with a strong primary care system will get delayed.

Even more important than sequencing is getting the primary healthcare system right. Here the two key challenges are designing the system that is both accountable and responsive. How well the new design is able to deal with these twin challenges will decide whether a strengthened primary care system will be able to regain the lost public trust in it.

The writer is a development economist, formerly with the Bill & Melinda Gates Foundation and the World Bank