Analysis Of Health Reform Implementation And Health Policies In India

Even though India has made strides in health outcomes in the past few decades, it is still plagued by inadequate financial coverage, poor access and substandard quality of care for its people. Acknowledging the linkage between health and economic growth, the union finance budget announced in 2018-19 sought to make progress in the health sector. It announced the Ayushman Bharat Program (ABP) which consists of two policy arms – Health and Wellness Centers for primary or preventative care and National Health Protection Scheme (also known as Pradhan Mantri Jan Arogya Yojana), a health insurance scheme for secondary and tertiary inpatient procedures.

The scheme was launched in September 2018.

This paper prospectively analyses the political economy of the Ayushman Bharat’s implementation across the nation. Firstly, the paper discusses the brief context of Indian health care system under which the Ayushman Bharat Program (ABP) was launched and the value proposition of the reform. Secondly, it describes the problem by elaborating on the political economy constraints and facilitators of the implementation of ABP.

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Thirdly, it sheds light on the lessons India can learn from Asian frontrunners of Universal Health Coverage – Thailand and Sri Lanka. This is followed by a suggestive framework for managing stakeholders in the health reform to tackle implementation challenges from a political lens (adapted from the framework proposed by Campos et al, 2018). Lastly, since this is a preliminary analysis for a very recent reform, the paper lists some caveats and areas for future research.

It is important to recognize that successful health reform outcomes require two levers – right design as well as right implementation.

As Ayushman Bharat has already been rolled out in September 2018, this paper does not focus retrospectively on the design of schemes, even though there are many implementation challenges which could have been addressed by tweaking the current policy design.

The current state of the health care sector in India

India’s budgetary allocation for health as a percentage of the gross domestic product has remained stagnant at approximately 1% in the last few years, even though the nominal value has increased over time. WHO’s health financing profile reflects the significant out-of-pocket expenditure incurred by Indians, at ~68% of the total health expenditure compared to the world average hovering around 18% for the same metric . India has a three-tiered system including primary, secondary and tertiary care; but the elaborate public primary care system delivers only 8-10%1 of the care sought by people. To aggravate the weak primary and preventative delivery of care, a quarter of the total public facilities account for three-fourths of total health services provided in public sector facilities, demonstrating the disproportionate pressure per facility.

Beyond this factual data, the poor quality of care in the public sector often compels people to seek care at private facilities. Families end up paying beyond what their pocket allows owing to the discretionary high prices in private hospitals. This further contributes to the high rate of catastrophic expenditures in India. Although the government focus has largely remained on access rather than quality, it is critical to note that quality affects several dimensions of service delivery, patient perception and health care utilization in the Indian context.

With little political agenda affiliated to health sector until now and the gap between national level policy mandates versus state-level implementation, Indian health care system is indeed ridden with many challenges (Figure 1, appendix). In this scenario, when the ‘Ayushman Bharat Program’ (ABP) was announced in 2018-19 union budget in the pursuit of Universal Health Coverage, it witnessed unprecedented media attention from local as well as the international community for its focus on overall ‘well-being’ rather than just ‘treatment’.

Ayushman Bharat Program’s value proposition – A Path towards Universal Health Coverage

The policy is an attempt to cater to the economically weaker sections of society via need-based health care procedures and services. The bold and ambitious reform includes a two-pronged approach (Figure 2, appendix).

Firstly, the aim is to create ‘Health and Wellness Centers’ (HWCs) for the provision of comprehensive Primary Health Care by 2022. This will be done by upgrading the existing sub - health centers to HWCs encompassing a broad package of twelve services ranging from maternal health, child health, mental health elderly and palliative health, management of communicable and noncommunicable diseases to ophthalmic or ENT problems. These centers are also envisioned to have wellness rooms for yoga, physiotherapy and telemedicine services.

Secondly, the progam includes rolling out the National Health Protection Scheme (NHPS) or now known as Pradhan Mantri Jan Arogya Yojana (PM-JAY), a government-sponsored insurance scheme that aims to protect families that are socio-economically disadvantaged. The scheme goes beyond the traditional route of targeting ‘below poverty line’ (BPL) population and instead its inclusion criteria is expanded to cater to ‘vulnerable and deprived population’ identified via the Socioeconomic and Caste Census (SECC). NHPS will provide coverage of up to ~$6700 (INR 0.5 million) per family each year covering ~100Mn families. The scope of services is limited to inpatient procedures only on an entitlement basis. These services can be accessed via empaneled health care providers (public or private). It will include all preexisting conditions, pre and post hospitalization and even transport allowance which often deters health seeking behavior in low- and middle-income countries.

To facilitate demand generation and utilization of services under the Ayushman Bharat Program, the policy seeks to launch health education campaigns and community mobilization drives. Since health care implementation is a state issue in India, the long-term goal is to merge the scheme with other state schemes even though the scheme is not mandatory for uptake as of now. The funding mechanism is 60:40 by center and state respectively. Overall, the reform intends to leverage private sector to a large extent – by inviting the private sector to assist in the process of establishing HWCs as well as empaneling private hospitals for the NHPS scheme’s provision.

Often touted as ‘Modicare’ as led by the incumbent Prime Minister ‘Narendra Modi’, the reform’s launch comes at a strategic time nearing the national elections in 2019. Even though the policy is intended to support a large population, it has challenges with respect to the actualization of the agenda it has set out to pursue.

Political analysis of Ayushman Bharat’s implementation – facilitators and constraints

Akin to many other countries pursuing health policy changes, India’s health care system has been unable to deliver on a number of initiatives in the past decades. People have witnessed substandard implementation and failed scale-up of many schemes proposing free treatment or diagnostics by the union and state authorities. Ayushman Bharat is a very ambitious reform and based on the trajectory of past performance of policies at ground level, it would be operationally challenging to minimize the ‘implementation gap’, that is the difference between what is expected from the policy versus what it finally achieves .

The peculiarities of the largest democracy in the world and of a health sector shaped by its decentralized central-state division of responsibilities comes with its set of challenges to orchestrate and implement policies at the point of delivery. Hence, a multitude of implementation challenges in the Indian context are more political than technical. In this light, the paper below analyses the health policy implementation with a political science angle – the various facilitators and constraints in this scenario.

The political factors which espoused the reform so far are essentially the facilitators which can lead to successful implementation of Ayushman Bharat unlike previous health policies in India. The most significant enabler is the fact that there are upcoming general election and assembly elections in a number of states. So, it is in the interest of political leaders to maintain the political commitment for actualizing the reform to win the 2019 elections. Thereafter whichever party comes into power at the federal level definitely cannot likely retract the benefits of the scheme from the people and should ideally work to ameliorate the scheme on account of the elected majority win. Secondly, this scheme is the pet project of current Prime Minister Modi reflecting support from people in high-level political power. In a recent political rally, he mentioned “The scale of this scheme is unparalleled, and it will bring a paradigm shift in our health sector.

It is time to give India a healthcare system that makes quality treatment affordable...” . Thirdly, Modi’s enthusiasm for the ABP is shared by the Finance Minister as well which is many times on the side of contention with Ministry of Health for an endowment of monetary resources. The union budget of 2018-19 explicitly includes a political acknowledgement of how ‘good health’ is associated with ‘economic growth’. The Union Finance Minister in his budget speech said: “Only ‘Swasth Bharat’(healthy India) can be ‘Samridha Bharat’ (prosperous India). India cannot realize its demographic dividends without its citizen being healthy.’ and ‘Ayushman Bharat Program will build a New India 2022 and ensure enhanced productivity, well-being and avert wage loss and impoverishment. These Schemes will also generate lakhs of jobs, particularly for women”. This political intent and announcement of the scheme caught the attention of multiple stakeholders including political figures, providers, media, international organizations and most importantly the prospective voters for the 2019 election.

However, implementation transcends much beyond political will, agenda-setting or provision of instructions in a policy document. The challenges and constraints of health reform implementation come into light when actions of multiple organizations and individuals have to be consolidated in a singular and coherent line of vision to affect a policy change. As Oliver (2006) aptly mentions, the most critical stumbling block in implementation is that the responsibility of implementation of health policy often lies in the hands of different actors than those who are engaged in planning and design of the same. Sometimes, these policies are designed from the ivory towers by people who do not have enough on-ground experience and this may lead to further dissonance in the perspectives of two stakeholders.

The systemic problems within the Indian political system and organization of health sector (figure 3, appendix) make the implementation of Ayushman Bharat prone to the danger of above-mentioned challenge resulting in ‘implementation deficit’ , as coined by Pressman and Wildavsky (1973). They also posit that “the longer the chain of causality, the more numerous the reciprocal relationships among the links and the more complex implementation becomes”. This long chain of relationships from planning to implementation is witnessed in the Indian health sector wherein Ayushman Bharat is drafted at national level, however provision of care is a state issue in India.

The states are responsible for organizing and delivering health services to the inhabitants. On the other hand, the central government oversees the international health treaties, medical education, prevention of food adulteration, quality control in drug manufacturing, national disease control, and family planning programs. Often, the central government sets national health policy while supporting the states in varying capacity. The ABP is a voluntary program for states and incorporates windows of flexible adjustments to adapt the reform based on the local situation for each state. So far, five states including Telangana, Odisha, Delhi, Kerala and Punjab have decided to opt out of the national program . Each of these states is waiting to get their concerns addressed and secure a better agreement with the center.

This impels the most critical constraint for implementation of Ayushman Bharat – limited buy-in, interest or technical capacity of individual Indian States. Even though the lack of buy-in and interest could be affected by multiple political reasons, technical capacity of states is an implementation challenge for which persuasion by the center to invest more in infrastructure and human resources is warranted for such states. Political tension surmounting between state leaders and Modi can challenge the ground level advancements of the policy for the people, for instance, the Chief Ministers of Kerala and Delhi have called Ayushman Bharat a ‘hoax’. Hence, the paucity of trust between center and state is an issue which needs major attention.

The reform is based on the concept of cooperative federalism which is far from the current reality. Therefore, it will be be a challenge unless all states agree to implement the scheme within the same ambit of vision. This may be a perplexing situation as many states have their own health insurance schemes and those need to be harmonized with the national level ABP, besides the socio-political conflicts.

These challenges get aggravated on account of a decentralized health sector. Even though states have streamlined locus of authority and competent bureaucratic actors, corruption among elected representatives or politicians often overrides internal bureaucratic accountability measures . The systemic corruption issues plague independence of bureaucrats and this, in turn inhibits their ability to leverage their power to act, even if monetary and fiscal support is present. The organization of institutional mechanisms including fiscal and administrative capacity has implication for service delivery and hence the implementation of this health reform. Since independence from British colonialism in 1947, there has been a steady increase over time in patronage politics and rent-seeking which has led to questionable quality of public health spending.

It is important to acknowledge that in the Indian context, the stakeholders of health reform which are farthest from the central decision-making unit and process pay the price for the same9, bolstering the claim of Pressman and Wildavsky (1973) cited above with respect to long chain of linkages. This suggests that making this distance shorter may facilitate the implementation of Ayushman Bharat at a state level. However, decentralization can be a double-edged sword and if crafted carefully in terms of the degree of decision space from planning, budgeting to service delivery along with an efficient management of stakeholder relationships, then decentralization can instead act as a facilitator in the health reform in India.

Further, there is a threat of change in political leadership in 2019 as the national sentiment is swinging based on a multitude of factors beyond health care (demonetization, farmer loans, religion etc.). This transient nature of current political leadership puts the whole policy in a gray zone from the perspective of the level of commitment and overriding vision.

Lessons from the Asian frontrunners (Thailand and Sri Lanka) for Universal Health Coverage scheme implementation

As India has publicly professed its commitment towards Universal Health Coverage (UHC) via incremental reforms, starting with Ayushman Bharat Program, it can draw on implementation lessons from developing economies in Asia which have already walked on that path. Deciding the tenets of UHC (what to cover, whom to cover and how much to cover) based on its feasibility of implementation is a learning process and countries often glean learnings once the proposed policies are up and running. In this case, it is significant for India to understand the context of reforms in other countries, how the political forces eliminated constraints for implementation and then adapt the learnings to its local country context.

 Lessons from Thailand

Thailand is one of the preliminary developing countries across the globe which reaped the gains of Universal Health Coverage via successful implementation of its reform starting approximately two decades ago. UHC was achieved in ~2002 with the “30-Baht for All Diseases Policy” after the new Thai Rak Thai (TRT) party was elected with an unprecedented majority. The reform also geared towards a demand-side financing and purchasing of health services akin to India . However, it differs from ABP in some ways because the 30-Baht policy introduced a capitation-based model (per member per month) while India’s model is largely fee-for-service with suggested rates for an array of inpatient procedures.

The historical development of health insurance system in Thailand can provide useful learnings for lower-and-middle income countries like India, especially with respect to the lens of politics during implementation of the health reform. Thailand demonstrated to the global community that UHC was possible to achieve even with a low GDP per capita. Even though several factors contributed to the success of UHC in Thailand, most significant ones include political commitment, focus on primary health care, strong network of bureaucrats and providers, active involvement of civil society organizations (CSOs) . Harris (2015) and Selway (2011) both cite the role of political forces, electoral reforms and some strong interest group stakeholders in agenda-setting as well implementation of the reform.

Firstly, based on Harris’s (2015) findings, India can translate Thailand’s effort to sustain political commitment by managing interest groups and bureaucrats effectively. The network of bureaucrats ‘Rural Doctors Network’ played an important role to mobilize the different resources ranging from leading political party, civil society organizations, international organizations and professional organizations. The “developmental capture”13 emphasized how adequate power in the hands of bureaucrats can assist in reducing the implementation gap of health policy reforms. The bureaucrats or other hidden specialists (doctors in the case of Thailand) often have political resources and capacities which are not recognized and as the case of Thailand shows, the Rural Doctor’s network leveraged their executive positions strategically to maneuver the implementation of reform. They even organized the civil groups, societal interest in the agenda for health and drew on the support from international organizations to bolster their action-plan. They clearly made the right use of their formal authority and help from informal networks at the right time to launch UHC as a ‘national pilot project’ before the policy had been passed by Parliament.

Secondly, the pursuit of UHC serves a lesson for strategically managing the political leadership so as to ensure will and commitment throughout. This is critical for India in the face of national elections in 2019. Combing the perspectives of Harris (2015) and Selway (2011), strong political