In Delhi, where politics, plans and parleys go hand in hand, they are calling it Jumanji—a dice game that could create trouble if played wrongly, even bring wild animals into your living room.
In short, the game—also a popular 1995 Hollywood movie—is an interesting one, but extremely difficult for the players to win. In the Indian capital, the Jumanji joke revolves around the much-hyped National Health Insurance Scheme (NHPS) that would cost the Modi government a whopping $1.7 billion annually. Expectedly, mandarins in the corridors of power in the Indian capital are wondering who will pull the rabbit out of the hat.
Everyone wants to change the face of India’s troubled healthcare system that suffers from multiple issues, the most prominent being the ratio of doctors per patients that stand at a pathetic one doctor per 1,700 patients. Recently, a quack injected HIV blood into over 25 patients in Unnao in Uttar Pradesh, triggering outrage across the country, while also highlighting the woes of healthcare system, especially in rural India.
On paper, NHPS looks very similar to National Rural Employment Guarantee Act (NREGA), the social welfare scheme announced by the previous UPA government and subsequently abused by a large number of state governments.
“It is the delivery mechanism which is the key, the government needs to make it totally full-proof,” says Devlina Chakravarty, CEO of Artemis Hospital in Gurgaon, during a discussion on the alarming rise of cancer. “This is an investment into health, everyone must be serious. The plans must not be on paper, it must be in the works,” she adds.
Health issues have rarely featured in Budget speeches, hence many were surprised to hear about the government’s new health scheme. It was instantly dubbed as NDA’s show stopper on multiple twitter handles and social media outlets. Modi himself called it the largest health scheme ever proposed anywhere in the world. Finance Minister Arun Jaitley, in his press conference, called it 'Modicare' in a dig at Washington that had once tom-tomed former US president Barack Obama’s social programmes as 'Obamacare'.
But the big question worrying many is simple: Is there enough cash in the government coffers for the big bucks programme? The budgetary outlay increase for health is—actually—trivial, nay, totally stagnant if one evaluates it in real terms. Why? The National Health Mission has reflected a decline in allocations; revised estimates for the health sector in 2017 were significantly higher than the initial budgetary allocation.
Lets look at the numbers first. India needs more resources to keep the essential operations going. The budgetary estimate for 2017-2018 was Rs 48,878 crore, the revised estimate is Rs 53,198 crore and the budgetary allocation for the current year is Rs 54,667 crore. “Well, 2018’s allocation on paper shows an increase of 11.8 per cent over last year’s allocation but if you take a realistic look, it is only a meager 2.7 per cent increase over the revised estimate. What is worrying is the that in terms of public health expenditure as a proportion of GDP, it has declined further,” says Dinesh Trivedi, MP, Trinamool Congress.
Trivedi says the NHPS is not new, it was announced in the 2016 Budget, but now the budget has been raised from Rs 150,000 to Rs 500,000. “Wish the scheme was operationalised, but that has not happened in the last two years and almost half the funds under the existing health cover scheme have been spent in the past year,” he adds.
Indranil Mukherjee, who teaches at the Jindal Global University and researches in health trends in India, says many states have better designed insurance schemes in place. He says time is a crucial factor is getting the funds in place, and it would be a herculean task. “You can safely say it will take six months for the scheme to take a definitive shape and another three months for the health ministry to award contracts to insurance agencies and providers. So, you have lost nine months and we are in February, 2018.”
But the ruling BJP-led NDA is not worried. If the scheme gets activated before the general elections in 2019, the coalition will get a great trigger of hope. “There will be enough spin doctors of the ruling party to feed news channels and newspapers and the health project will become a great talking point,” says Vandana Kumari Singh of SJP.
She quotes the National Sample Survey to show how existing government health insurance schemes that cover close to over 40 crore people are floundering because of lack of cash. Worse, catastrophic health expenditures remain at more or less the same levels, with and without government-funded insurance coverage. “And we do not know if these schemes will improve access to hospitalisation.”
Singh says BJP’s Catch-22 situation could emerge from the financial requirement for the scheme, which would amount to not less than Rs 30,000 crore (if one calculates it at the rate of Rs 3,000 per household). The health ministry, says Singh, could push the states to include the state schemes in the programme, but the states—especially the ones not ruled by the BJP—may not agree.
Experts claim the government should have made it clear how it wants to regulate the private hospitals, which are often blamed for irrational and unnecessary care. The government has also not made it clear how will it bridge the gap of low reimbursement rates in existing schemes that keep the elite hospitals away from the masses.
“Some empanelment must happen and there are high chances that private hospitals would have a great advantage over the rest. Corporate hospitals have always demanded high reimbursement, if that if provided, the advantage that affordable private care providers have will be lost. NHPS looks like corporate consolidation,” says Adhir Chowdhury of Congress.
“Modicare is a powerful electoral strategy. The government should know the poor get only 40 per cent of their hospital expenses from the insurance companies...The common man needs to get rid of such worries. Only then Modicare will be a success,” adds Chowdhury.
Health and Family Welfare Minister J.P. Nadda is aware of the challenges; his ministry is scouting for the world’s best technology to plug loopholes while rolling out the NHPS.
Someone should remind Nadda that health works best when it has a human touch.