India is in the midst of a remarkably ambitious health insurance expansion. In September 2018, Prime Minister Narendra Modi announced a plan that will cover an additional 500 million Indians.1 The motivation? India grossly underspends on health care, and health outcomes in some regions are among the worst in the world.2 For an emerging economic superpower, India’s health care spending, accounting for less than 4% of its gross domestic product, is woefully low, and it has fallen since 2000. The majority of spending is out of pocket, burdening the middle class and the poor. Given the country’s epidemiologic profile — India sees nearly a third of the world’s tuberculosis cases and faces a growing burden of chronic disease — failures to invest in health have shackled the Indian economy. Government leaders, irrespective of party, now recognize that India’s economic progress depends on the health of its people.
India’s health reform, Ayushman Bharat (“long life for India”), has two pillars: health insurance covering up to $7,000 (500,000 Indian rupees) of care per family per year for the poorest 500 million people (regardless of preexisting conditions) and reinvestment in primary care by transforming existing facilities into 150,000 new “Health and Wellness Centers” that provide comprehensive primary care. Historically, primary care has been underfunded and disconnected from secondary and tertiary care; weak primary care has made it difficult to effectively reduce unnecessary, high hospital costs. As part of its reform, the government has created a National Health Authority to administratively link primary care and insurance expansion to foster better coordination across the continuum of care. Ayushman Bharat is seen as an important step toward achieving universal health coverage and the United Nations Sustainable Development Goal 3 (“good health and well-being”).
Though these goals are laudable, there are substantial obstacles to achieving them. The reform can succeed only if particular attention is paid to ensuring true financial protection, expanding workforce capacity by leveraging emerging technology, and improving the quality of care. Failure to address these aspects will hinder achievement of the reform’s goals and make other countries less willing to pursue universal health coverage.
A major reform goal is to provide financial protection. Catastrophic health expenditures send countless lower- and middle-income Indians into poverty, to say nothing of the devastating impact of such spending on impoverished families who accumulate multigenerational debt obtaining treatment for loved ones. Policymakers have assumed that health insurance eliminates — or at least substantially reduces — catastrophic health care spending. Surprisingly, this assumption may be invalid. A recent analysis revealed little correlation between the proportion of people in a population covered by insurance schemes and the proportion who end up with catastrophic health care spending (there is no single definition of catastrophic spending, though experts use 10% or 25% of annual household income). For example, in China, where 90% of the population has health coverage, 18% still have catastrophic expenditures, while in India, where only 20% of the population has coverage, 17% have such expenditures.3
Why aren’t coverage and protection correlated? Insurance schemes are often shallow, covering limited services or capping coverage. Catastrophic spending that sends people into debt frequently results from severe illness (stroke, major injury, or cancer) that necessitates substantial and sustained spending. Patients quickly spend beyond their insurance caps and must cover additional costs out of pocket; insurance schemes with caps, unless generously funded, offer insufficient protection to the sickest people. Ayushman Bharat’s spending cap of $7,000 per family may not keep sick patients out of debt. Given the costs of increasing the program’s generosity, one way to expand the depth of coverage is by introducing cost sharing at low levels of spending and progressing to full coverage as income-adjusted, out-of-pocket maximums are reached. Though the scheme covers some posthospitalization costs, it will need to be substantially augmented if it is to address India’s high out-of-pocket expenditures, especially for medicines and outpatient care.
A second challenge is that India’s health system is unprepared for 500 million additional people to begin using its services. In some regions, the dearth of hospitals may limit the rate at which care can be provided to additional people. With respect to the health workforce, policymakers have long focused on training more doctors and nurses; with increasing demand, the inadequacy of the workforce will come into sharper relief. Clearly, millions of doctors and nurses cannot be properly trained quickly. Although India has invested heavily in community health workers, the full potential ability of these workers to meet the needs of the population remains largely untapped. To harness this ground force, the health care system can leverage technology. Often in the history of Indian health care reform, primary care clinics have been constructed, only to be bypassed by patients in favor of hospitals, whose providers are better trained and supported. More point-of-care testing, as well as remote, supportive supervision involving the use of artificial intelligence, including dynamic clinical algorithms and computerized clinical decision-support systems, could substantially boost the capabilities of frontline workers.4 Such an effort would take more than distributing smartphones. Tailored tools for the local context and multiyear investments in training, capacity building, and evaluation could help address the needs of a vast population.
Third, it’s important to ensure the measurement and tracking of health care quality. What do we know about the state of health care quality in India today? There is evidence that a patient visiting a provider in India is more likely to emerge with the wrong diagnosis and inappropriate treatment than with the right diagnosis and treatment.5 For any scheme that aims to improve access, adverse events pose serious threats. Past attempts to increase access (e.g., conditional cash transfers aimed at reducing maternal mortality) failed to improve outcomes, most likely because they increased access to poor-quality care. What can India do to demonstrate its commitment to quality? Investments in collecting data in electronic records that systematically measure quality are part of the solution, but we believe that a national program that defines and tracks quality across the spectrum of care is crucial. Beyond the health benefits of improving quality, such programs build trust, encouraging people to return. Without deliberate attention to and action on quality, it’s unlikely that the reform will lead to better health outcomes.
The Indian health insurance scheme will be studied closely. Five Indian states are opting out of the reform; the reach and success of Ayushman Bharat will be determined in part by the ability of these states to effectively demonstrate that their models are expanding access, providing financial protection, and improving health outcomes. Parts of India have health indicators comparable to those of southern Europe, while other areas mirror parts of sub-Saharan Africa. No single strategy will work, but India’s diverse landscape also means that an extraordinary learning opportunity for implementing universal health coverage on a vast scale is unfolding. If the government invests heavily in evaluations, testing new approaches, and listening intently to states, it can ensure that relevant lessons are learned.
India’s bold step toward reform reflects an increasingly interconnected world and the desire of all people to have access to the fruits of modern medicine. From Mexico in 2006, to the United States in 2010, to China in 2016, to India now, universal coverage has become reform’s rallying cry. A high-profile failure, however, will set this movement back. India has the formula to succeed, and we believe the emphases outlined here can help India show the world that health care for all is eminently possible, even in the most complex of circumstances.