The Ayushman Bharat Evolution: From Targeted to Universal

The Original Vision and Its Limitations

When Ayushman Bharat PM-JAY was launched in 2018, it represented the world’s largest health insurance scheme, covering 10.74 crore families with ₹5 lakh annual coverage. The scheme’s socio economic targeting mechanism, based on the Socio-Economic Caste Census (SECC) 2011 data, aimed to identify the most vulnerable populations. However, this approach created artificial boundaries that excluded many middle-class families who couldn’t afford private healthcare but didn’t qualify for government assistance.

The scheme’s implementation revealed both strengths and weaknesses. On the positive side, it created a vast network of empaneled hospitals, established standardized treatment protocols, and introduced digital infrastructure for claim processing. The National Health Authority’s data shows that over 5 crore treatments have been authorized under PM-JAY, with a total claim value exceeding ₹70,000 crores.
However, the limitations were equally apparent. Rural areas struggled with hospital availability, with many districts having fewer than five empaneled facilities. The scheme’s focus on secondary and tertiary care, while necessary, didn’t address the primary healthcare gaps that prevented early intervention. Most critically, the income-based eligibility criteria created a coverage cliff—families just above the poverty line found themselves in a healthcare no-man’s land.

The Vaya Vandana Paradigm Shift

The Ayushman Vaya Vandana Card addresses these limitations through a fundamentally different approach. By providing universal coverage to all citizens above 70, regardless of economic status, it acknowledges that healthcare needs transcend socio-economic boundaries, particularly for vulnerable populations like the elderly. This shift is demographically prescient. India’s elderly population (60+) is projected to grow from 104 million in 2011 to 319 million by 2050. The 70+ demographic, currently around 50 million, faces the highest healthcare costs due to multiple chronic conditions, frequent
hospitalizations, and complex treatment requirements. The scheme’s universal approach eliminates the bureaucratic hurdles and social stigma often associated with means-tested programs. The rapid enrollment—over 28,000 in Delhi within a week—demonstrates pent-up demand. More significantly, it reveals the inadequacy of existing coverage mechanisms. If middle-class seniors are rushing to enroll in a government scheme, it indicates that private insurance and out-of-pocket payments have failed to provide adequate financial protection.

The Financing Crisis: Numbers Don’t Lie

The Expenditure Gap

India’s healthcare financing presents a sobering picture that no amount of political rhetoric can obscure. At 1.3% of GDP, our public health expenditure ranks among the lowest globally. To put this in perspective, countries with successful universal health systems spend significantly more: the UK (7.5%), France (8.1%), Germany (9.4%), and even middle-income countries like Thailand (2.7%) and Brazil (4.2%).

This chronic underfunding manifests in multiple ways. The per capita public health expenditure in India is approximately $19, compared to $3,000 in developed nations and $75-150 in comparable middle-income countries. Even accounting for purchasing power parity, the gap remains substantial. The Fifteenth Finance Commission’s recommendation to increase public health expenditure to 2.5% of GDP by 2025 represents progress, but even this target falls short of what’s needed for universal coverage. Health economists estimate that achieving comprehensive universal health coverage would require 3-4% of GDP in public spending, implying a tripling of current expenditure levels.

The Out-of-Pocket Burden

Perhaps more troubling is India’s reliance on out-of-pocket expenditure, which accounts for nearly 65% of total health spending—among the highest globally. This means that most healthcare costs are borne directly by families, often leading to catastrophic expenditure and
medical bankruptcy. The National Sample Survey Office (NSSO) data reveals that healthcare expenses push approximately 7% of the population below the poverty line annually. In rural areas, nearly 24% of hospitalization cases result in catastrophic expenditure (exceeding 10% of household consumption), while in urban areas, the figure is 18%. This financial burden disproportionately affects vulnerable populations. Scheduled Castes and Scheduled Tribes face higher out-of-pocket payments relative to their income levels. Women often delay or forgo treatment due to financial constraints and social prioritization of male family members’ health needs.

Insurance Coverage Gaps

Despite the expansion of health insurance through various schemes, coverage remains inadequate and fragmented. The National Family Health Survey-5 (2019-21) shows that only 41% of households have any health insurance or financial protection for health. Even among covered populations, the depth of coverage is often insufficient. Private health insurance, while growing, covers only 17% of the population, primarily urban, educated, and affluent segments. Premium increases of 15-20% annually make private insurance increasingly unaffordable for middle-class families. Moreover, private policies often exclude pre-existing conditions, impose waiting periods, and limit coverage for chronic diseases precisely the areas where coverage is most needed.

Infrastructure Deficits: The Ground Reality

Healthcare Facility Shortages

India’s healthcare infrastructure reveals stark inadequacies that undermine policy ambitions. The country has approximately 0.7 hospital beds per 1,000 population, significantly below the WHO recommendation of 3-5 beds. This translates to a shortage of over 2 million hospital beds nationally. In the state capital, state-owned healthcare facilities are actively addressing a staff shortage challenge. At King George’s Medical University (KGMU), there are currently 712 out of 1,230 sanctioned positions that need to be filled. This situation arises despite the state approving an additional 525 doctor positions last year, bringing the total number of posts to 718. According to KGMU spokesperson Dr. KK Singh, “Until last year, only 187 of the sanctioned positions were vacant. The state government has taken a positive step by approving 525 more professor positions for KGMU, and we are now working on recruitment drives to fill these roles effectively.”

At Balrampur Hospital, 34 out of 104 doctor positions are currently vacant, and at Lok Bandhu Hospital, there are 15 out of 88 sanctioned positions available. This information, shared by hospital officials under the condition of anonymity, highlights the ongoing efforts to enhance staffing and improve healthcare services in the region. With focused recruitment initiatives, there is potential for significant progress in addressing these vacancies and strengthening the healthcare workforce.

Quality Standards Crisis

“Ramesh, a 32-year-old construction worker, first visited his local clinic when he was having a persistent cough that refused to go away. For over two months, he had been suffering from coughing, recurring fever, and unexplained weight loss. The classic symptoms that should have raised red flags for tuberculosis (TB). But due to limited infrastructure and inadequate diagnostic support, his condition was misread as simple bronchitis. The technician, lacking proper training and resources, failed to spot early signs of TB. The doctor, relying on this flawed report, prescribed a general course of antibiotics and sent Ramesh home. Two more painful months passed. Ramesh’s condition worsened. His cough began producing blood, and severe fatigue left him unable to work. “

This story highlights a significant systemic failure in our country. Low-quality diagnostic services, often caused by under-resourced facilities, a lack of quality checks, and insufficient training, result in misdiagnosis, delayed treatment, worsening health, and increased healthcare costs.

According to the National Health Profile 2023, only 12% of primary health centers (PHCs) in India have diagnostic laboratories, and many of these do not meet even basic quality standards. This creates a significant diagnostic gap in rural areas, causing patients to turn to unregulated and

low-quality private labs. The consequences are severe: delayed or missed diagnoses, prolonged illness, high out-of-pocket expenses, and ultimately, preventable deaths. While decentralized diagnostics are essential, India must also invest in national reference laboratories to support complex testing and surveillance. Establishing 50 NABL-accredited reference labs, each serving approximately 25 million people, would provide comprehensive national coverage. These centers should be equipped with AI-assisted digital microscopy, real-time PCR machines, and cloud-based data systems for seamless integration into the healthcare system.

Public-private partnerships can be utilized to train laboratory personnel at these reference centers, ensuring they acquire both theoretical knowledge and practical skills. The curriculum should focus on AI tools, quality protocols, and patient-centered diagnostic delivery. Diagnostics are not merely support tools; they are central to effective healthcare delivery. Without timely and accurate testing, even the best clinical decisions can fail. As India aims for Universal Health Coverage and a $5 trillion economy, strengthening diagnostic services, especially at the grassroots level, is not optional; it is an urgent public health imperative.

Governance Challenges: The Coordination Crisis

The Federal Tug-of-War

Lately, the central government has been stepping up its role in healthcare, and there are a few reasons for this shift. One key reason is the growing significance of global public health, which is reshaping the relationship between central and state governments. Over the past ten years, we’ve seen a significant expansion in international public health standards. The World Health Organization (WHO) has introduced crucial guidelines for its member countries regarding disease tracking and responses to health threats. Often, these global regulations prioritize health emergencies, such as pandemics, over national sovereignty, which means that countries have to fulfill these international commitments.

In many federal nations, including India, governments have leveraged these international agreements to establish national health laws. This sometimes curtails the authority of state governments. A prime example is the National Rural Health Mission (NRHM), initiated by the United Progressive Alliance government in 2005. This program was heavily influenced by concepts from organizations like the World Bank and the WHO, which left states with minimal input in its development. Nowadays, the emphasis has shifted towards making districts the focal points for health initiatives, often sidelining state governments in the process of tackling coordination challenges.

The second major shift in Health federalism is currently experiencing a significant transformation, largely driven by rapid technological advancements, particularly the ongoing data revolution that utilizes data clouds transcending physical borders. This surge in health data from diverse sources necessitates centralized management to facilitate effective policymaking, which in turn impacts local autonomy.

Take, for instance, the federal government’s National Digital Health Blueprint (NDHB), which is working towards establishing an integrated health information system. The goal here is to enhance transparency, boost efficiency, and elevate the quality of care for citizens. While the NDHB is managed at the federal level and aims to collaborate effectively with both public and private entities, it unfortunately lacks the active participation of state governments.

In conclusion, the emergence of digital technology and the data revolution in healthcare are having a profound effect on health federalism. The third and most significant shift in health federalism has been triggered by the impact of the COVID-19 pandemic has changed the game when it comes to health federalism. The rapid spread of the virus pushed the Central government to act swiftly. With no clear laws in place to handle the crisis, they turned to emergency powers granted by the Disaster Management Act of 2005. This gave them the authority to enforce national lockdowns and quickly roll out measures for producing, purchasing, pricing, and distributing vaccines to help control the outbreak.

While these actions were crucial, they did impact the dynamic between the Centre and the states. As the pandemic dragged on, many states, particularly those led by opposition parties, accused the federal government of overreaching and infringing on their rights regarding health service delivery.

Moreover, the challenges in coordination between the Centre and the states during this time have prompted some experts and policymakers to advocate for reforms. They argue that the shortcomings revealed in the Indian federal system during the pandemic should lead to health being moved to the “Concurrent List.” This shift would empower the federal government to take a more significant role in health matters, much like it does in education.

Global Lessons: Learning from Success and Failure :

The British NHS Model: Universal Access Through Taxation

The National Health Service (NHS) in the UK was set up in 1948 as a groundbreaking initiative to ensure everyone has access to healthcare, funded through taxes. The beauty of the NHS is that it provides free healthcare to anyone who needs it, with a tax system that asks more from those who earn more.

The NHS boasts several advantages. It guarantees healthcare access for all, keeps costs in check, and emphasizes primary care. Thanks to this, the UK enjoys impressive health outcomes, including high life expectancy and low infant mortality rates. Most importantly, healthcare is available to everyone, no matter their financial situation.

That said, the NHS is grappling with significant challenges that could offer valuable insights for India. Ongoing funding struggles have resulted in long wait times for non-urgent surgeries, with some patients waiting over a year. Additionally, the system is feeling the strain from a growing demand due to an aging population and rising healthcare expenses.

For India, the NHS model holds important lessons. First, achieving universal access through taxation is feasible, but it demands strong political backing and adequate funding. Second, a robust primary care system can help minimize expensive hospital visits. Third, while centralized purchasing can help control costs, it might also restrict choices and stifle innovation.

Furthermore, the NHS’s recent emphasis on digital health and integrated care could serve as a roadmap for India’s digital health initiatives. However, the UK’s more uniform population and centralized management make it challenging to directly apply this model in India’s diverse and intricate landscape.

China’s Healthcare Reforms: Scale and Speed

China’s healthcare reforms since 2009 provide a fascinating look at how a large and diverse nation can transform its health system. In just ten years, China managed to achieve nearly universal insurance coverage and significantly boost public health spending.

The strategy focused on expanding insurance coverage, strengthening primary care, and reforming public hospitals. The country poured resources into healthcare infrastructure, building thousands of community health centers and training millions of health workers.

However, these reforms also highlighted some challenges. Even with universal coverage, many people still face high out-of-pocket expenses, and the quality of healthcare can vary widely from one region to another. The system grapples with issues like inefficient resource allocation and misaligned incentives.

For India, China’s journey underscores the need for comprehensive reforms that address financing, delivery, and governance all at once. Simply expanding insurance isn’t enough if the underlying supply-side issues and quality concerns aren’t tackled.

Germany’s Social Insurance Model: Balancing Public and Private

Germany boasts a healthcare system that cleverly blends social insurance with regulated competition. This setup aims to strike a balance between public services and market-driven approaches. Impressively, it covers 99% of the population, with 85% relying on statutory health insurance and the remaining 15% opting for private insurance.

There are plenty of strengths in the German system. It ensures universal coverage, enjoys high patient satisfaction, and effectively manages costs. While there’s competition among various insurance funds, it also fosters solidarity through risk pooling and contributions based on income. This combination contributes to high life expectancy and low mortality rates.

On the flip side, the system can be quite complex. The multitude of insurance funds, intricate regulations, and the mix of public and private options lead to a fair amount of administrative work. Additionally, the system relies heavily on a robust formal economy to gather insurance contributions, which poses a significant challenge for India, given its large informal sector.

India could take a page from Germany’s playbook, particularly in areas like regulated competition and risk pooling. By focusing on preventive care and effectively managing chronic diseases, Germany’s approach could provide valuable insights for India as it grapples with rising health challenges. However, for India to successfully implement social insurance, it would need to formalize its economy and enhance its regulatory frameworks.

Technology as a Game Changer: The Digital Health Revolution :

The Digital Health Mission’s Promise

India’s Ayushman Bharat Digital Mission (ABDM) is a groundbreaking initiative in the realm of digital health. Its goal is to seamlessly connect patients, healthcare providers, and health records into a unified system that spans the entire country.

At the heart of the ABDM are unique health IDs for every citizen, comprehensive lists of healthcare providers, and systems designed to facilitate easy sharing of health information. This approach aims to streamline information exchange, reduce medical errors, and enhance the overall quality of care.

So far, the initial outcomes are promising. Several states have begun issuing health IDs, and pilot projects are demonstrating the system’s potential effectiveness. The mission also emphasizes the importance of data sharing with consent and safeguarding privacy, addressing crucial concerns surrounding digital health systems.

Nonetheless, significant challenges remain. A considerable number of individuals, particularly the elderly and those living in rural areas, struggle with low digital literacy. Additionally, healthcare providers in these rural regions often lack the necessary tools and training to effectively utilize digital systems.

Telemedicine’s Transformative Potential

The COVID-19 pandemic accelerated telemedicine adoption in India, demonstrating its potential to bridge geographic access barriers. The expansion of Tele MANAS to handle over 17.6 lakh mental health calls shows how technology can address specialized care shortages.

Telemedicine offers particular promise for chronic disease management, where regular monitoring and consultation are required but don’t always necessitate physical examination. Diabetes, hypertension, and mental health conditions—major health challenges in India—are well-suited to telemedicine interventions.

However, telemedicine’s effectiveness depends on adequate digital infrastructure, provider training, and patient education. Rural areas often lack reliable internet connectivity, limiting telemedicine’s reach precisely where it’s most needed.

Artificial Intelligence and Diagnostics

AI applications in healthcare offer significant potential for India, particularly in diagnostics and screening. AI-powered screening for diabetic retinopathy, tuberculosis detection in chest X-rays, and automated ECG interpretation can extend specialist expertise to underserved areas.

Several Indian companies and research institutions are developing AI solutions for healthcare. However, most applications remain in pilot stages, and regulatory frameworks for AI in healthcare are still evolving.

The key challenge is ensuring AI applications are validated for Indian populations and healthcare contexts. Most AI algorithms are trained on data from developed countries, potentially limiting their applicability to Indian patients and healthcare settings.

The Way Forward: A Comprehensive Reform Agenda :

Short-term Priorities (1-3 years)

The immediate priority must be strengthening the foundation of India’s healthcare system while building on recent initiatives like Ayushman Vaya Vandana.

Financing Reforms: Increase public health expenditure to 2% of GDP within three years through progressive budget reallocation and new revenue sources. Implement outcome-based budgeting to ensure resources translate into improved health outcomes.

Infrastructure Acceleration: Fast-track the Health and Wellness Center program to establish comprehensive primary care networks. Focus on rural and underserved areas where infrastructure gaps are most acute. Ensure centers are adequately staffed and equipped before declaring them functional.

Human Resource Emergency Response: Implement a national healthcare workforce emergency plan including accelerated training programs, rural service incentives, and improved working conditions in public facilities. Create fast-track licensing for qualified foreign healthcare professionals to address immediate shortages.

Digital Health Foundation: Accelerate ABDM implementation with a focus on interoperability and user experience. Ensure digital systems enhance rather than complicate healthcare delivery. Prioritize rural connectivity and digital literacy programs.

Quality Assurance Systems: Establish mandatory minimum quality standards for all healthcare facilities. Implement systematic patient safety monitoring and medical error reporting systems. Create patient feedback mechanisms to drive continuous improvement.

Medium-term Transformation (3-7 years)

The medium-term focus should be on systemic transformation that addresses root causes rather than symptoms.

Universal Health Coverage Architecture: Design and implement a comprehensive UHC system that integrates existing schemes while expanding coverage to currently excluded populations. Move beyond insurance toward integrated service delivery networks.

Preventive Care Revolution: Shift healthcare focus from curative to preventive care through comprehensive lifestyle intervention programs, community health initiatives, and environmental health improvements. Integrate prevention into all healthcare settings.

Healthcare Workforce Transformation: Restructure medical and nursing education to emphasize primary care, rural service, and community health. Create new cadres of healthcare workers suited to Indian conditions. Implement continuous professional development systems.

Technology Integration: Deploy AI, telemedicine, and digital health tools at scale. Ensure technology augments human capabilities rather than replacing human connection in healthcare. Address digital divides that could exacerbate health inequities.

Governance Strengthening: Establish unified healthcare governance systems that coordinate across levels of government and sectors. Implement performance management systems that reward outcomes rather than outputs.

Long-term Vision (7-15 years)

The long-term vision should position India as a global leader in equitable, efficient, and innovative healthcare delivery.

Health System Maturity: Achieve healthcare system performance comparable to develope countries while maintaining affordability and accessibility. Establish India as a model for other developing countries.

Innovation Leadership: Become a global leader in healthcare innovation, particularly in areas relevant to developing countries. Export Indian healthcare innovations and expertise to other nations.

Health Equity Achievement: Eliminate health disparities based on geography, income, gender, and social status. Ensure that health outcomes depend on individual biology rather than social circumstances.

Sustainable Financing: Establish sustainable healthcare financing that doesn’t depend on out-of- pocket payments or external assistance. Create financing mechanisms that are equitable, efficient, and politically sustainable.

Global Health Contribution: Contribute significantly to global health improvement through research, innovation, and technical assistance. Position India as a responsible global health leader.

Conclusion: The Imperative for Transformation

India is standing at a pivotal moment in its healthcare journey. The introduction of Ayushman Vaya Vandana marks a crucial step towards achieving universal health coverage, yet numerous challenges still lie ahead. The country faces a choice: should it opt for minor enhancements, or fully commit to a transformative overhaul to meet the demands of the 21st century?

The rising demand for healthcare, driven by population growth and economic development, is stretching our current system to its limits. The COVID-19 pandemic has brought this issue to the forefront, and as we look ahead, challenges like potential new pandemics and an aging population will only complicate matters further.

Research indicates that countries that invest early and comprehensively in healthcare tend to achieve better outcomes at lower costs. For instance, Thailand’s swift transition to universal coverage and Rwanda’s rebuilding of its health system post-conflict demonstrate that significant change is achievable with strong political will and effective strategies.

However, implementing change involves making tough choices about how to allocate resources and ensuring ongoing political backing, even when the financial burden is heavy. The alternative—staying stuck in dysfunction—will only lead to more suffering and greater inequalities. The Ayushman Vaya Vandana Card offers a pathway to establishing a universal healthcare system, but simply having insurance isn’t sufficient. We need to tackle issues related to the quality of care, supply chain challenges, and gaps in preventive measures.

India’s healthcare reform must be all-encompassing, addressing financing, infrastructure, workforce, governance, and quality in tandem. Piecemeal reforms could inadvertently create new issues without resolving the core problems. Moreover, the choices India makes will resonate on a global scale. A successful transformation could demonstrate that large developing nations can achieve health equity, while a failure might imply that universal health coverage is still a luxury reserved for wealthier countries. The opportunity for transformation is narrowing. Political cycles limit the chances for reform, and the pandemic has underscored the urgency for swift action.

Ultimately, India must choose between a healthcare system where access depends on location, income, and social status, or one that ensures health as a basic right. The Ayushman Vaya Vandana Card presents the opportunity for bold action, but the key question is whether India will act now to create a healthcare system that reflects its values and goals. India’s healthcare future depends on the choices made today. The chance for real change may not come again soon. We must decide: will India take action now or stick with a failing system? For the sake of future generations, the choice is clear: comprehensive transformation must start now.

The post India’s Healthcare Revolution: Bold Steps Forward, Miles to Go appeared first on InnoHEALTH magazine.

In this episode of InnoHealth Magazine’s podcast, we have the privilege of speaking with Dr. Param Hans Mishra, a distinguished figure in the realm of hospital administration in India. With an impressive background in strategic planning and a robust academic foundation, Dr. Mishra has made significant strides in optimizing hospital departments and enhancing business outcomes. His journey is marked by hard work, adaptability, and a commitment to excellence in healthcare leadership. Dr. Mishra’s strategic planning skills have optimized critical hospital departments such as Wards, ICU, and Emergency services. His adept business strategies led to a remarkable increased revenue in ISIC by 300% in 6 in 9 years and 60% in IQ City Hospital in 1 year. He is known for his exceptional management of diverse teams, from doctors to marketing professionals. Dr. Mishra is also recognized for organizing Continuous Medical Education (CME) camps and strategic advertising campaigns. Having following academic qualifications: MBBS, MHA(AIIMS), DNB, PGDHHM, PGDIM, IIM(Ahd) MDP. He epitomises excellence in Hospital Planning and Administration.

The Journey into Hospital Administration

Dr.Mishra’s journey into hospital administration began with his realization of the broader impact he could make beyond treating individual patients. He believes that a medical administrator can help a large number of patients by implementing patient-centric policies, developing infrastructure, and ensuring that hospitals are patient-friendly. His education at AIIMS in the Master of Hospital Administration program, which started in 1965 and remains highly competitive, laid a solid foundation for his career.

The Role and Evolution of Medical Administration

Medical administration is a challenging yet highly satisfying field. Over the years, it has evolved from senior doctors transitioning into administrative roles to a specialised field requiring professional qualifications. Dr. Mishra emphasises the importance of having professionally qualified hospital administrators, which has significantly improved the efficiency and management of hospitals. Institutions like IIHMR, Symbiosis, and TISS Mumbai are now producing brilliant hospital administrators, highlighting the growth and importance of this field.

Effective Coordination and Use of Technology

Effective coordination among different departments within a healthcare facility requires a dedicated team and the right tools. Modern hospitals utilize software and dashboards to monitor progress and facilitate coordination. Dr. Mishra stresses the importance of management by walking around, interacting with people, and taking facility rounds to understand and address actual problems. Digital tools complement these efforts by providing real-time data and monitoring capabilities.

Benefits of Electronic Medical Records (EMR)

The integration of Electronic Medical Records (EMR) is crucial for segregating and analyzing patient data efficiently. EMRs allow quick retrieval of patient information, facilitating research and improving patient care. Despite some resistance from doctors accustomed to handwritten records, the shift to EMRs is essential for reducing errors and enhancing the accuracy of medical records. Dr. Mishra advocates for the widespread adoption of EMRs, acknowledging the challenges but emphasising the long-term benefits.

Challenges and Solutions in Digital Health Records

While digitalization brings numerous benefits, it also raises concerns about data security and patient confidentiality. Dr. Mishra acknowledges that security issues exist with both hard copies and digital records. However, electronic records often provide better security through access controls and change logs. Cloud-based solutions further enhance the safety and accessibility of medical records.

Innovations in Healthcare Technology

Dr. Mishra highlights the potential of artificial intelligence and robotic systems in healthcare. These technologies promise to revolutionize medical specialties and treatment methods. However, he cautions against over-dependence on technology, advocating for a balanced approach that leverages technological advancements while maintaining the human element in patient care.

Health Insurance and Healthcare Delivery

Health insurance plays a vital role in shaping healthcare delivery and management. Dr. Mishra praises the Ayushman Bharat scheme but suggests making health insurance mandatory in India. This would prevent people from losing their valuables for medical treatment and ensure access to quality healthcare. He also calls for rationalizing insurance rates to ensure that hospitals can provide quality services without financial strain.

Standardization of Hospital Rates

The standardization of hospital rates, particularly aligning them with CGHS rates, is a contentious issue. Dr. Mishra believes that while rationalization is beneficial, making everything at CGHS rates is impractical. He suggests revising CGHS rates to reflect market conditions better and ensuring that hospitals are not forced to compromise on service quality.

Sustainable Practices in Healthcare

Sustainability in healthcare involves investing wisely and focusing on actual treatment rather than building extravagant facilities. Dr. Mishra advocates for medium-level hospitals with competent doctors who can provide quality care without exorbitant costs. Hospitals should also be conscious of resource usage, particularly in supply management, to minimize waste and reduce operational costs.

Reintroduction of Indian Medical Services

The reintroduction of Indian Medical Services (IMS) is seen as a positive step, but Dr. Mishra highlights the need for adequate infrastructure and support for doctors in remote locations. To fully utilize their talent, IMS officers should be provided with facilities comparable to those of IAS officers, ensuring they can perform effectively and efficiently.

Advice for Aspiring Healthcare Administrators

Dr. Mishra advises young students entering the field of healthcare administration to embrace the challenges and commit to continuous learning. He emphasizes the importance of financial and technology management skills, effective communication, and a patient-centric approach. Aspiring administrators should avoid a bossy attitude and focus on being facilitators and coordinators, supporting the doctors and nurses who are the backbone of any hospital.

Dr. Param Hans Mishra’s insights and experiences provide valuable lessons for anyone interested in hospital administration. His dedication to improving healthcare delivery through strategic planning, effective management, and embracing technological advancements sets a benchmark for excellence in healthcare leadership.

The post Navigating the Shift: Exploring Hospital Administration in India appeared first on InnoHEALTH magazine.

India too is urbanizing rapidly, in alignment with the global trend. As per the Census of India, the population in urban areas has increased from 286.1 million in 2001 to 377.1 million in 2011 (projected 483 million, in 2022).

Urbanization is one of the leading global demographic trends with a significant impact on the health and well-being of the population. As per World Health Organisation (WHO), more than 55% of the world’s population lives in urban areas, which is likely to increase to 68% by 2050. This scenario puts great demand on governments across the globe to address the varied vulnerabilities and issues affecting the health issues and health outcomes of urban populations. As most of the urban population growth will occur in developing countries, their governments have a unique opportunity to plan and guide urban development in a way that favourably affects the health and well-being of the urban population.  

India too is urbanizing rapidly, in alignment with the global trend. As per the Census of India, the population in urban areas has increased from 286.1 million in 2001 to 377.1 million in 2011 (projected 483 million, in 2022). The urban population constitutes 31% of the total population in India and is expected to increase to more than 550 million by 2030. 

The unprecedented growth of this scale comes with issues such as disparities, inadequate urban housing and infrastructure, overcrowding, insufficient urban amenities, etc. An increasing number of communicable and non-communicable diseases, malnutrition among children, insufficient water and sanitation facilities, etc., affect the health status of the urban population. According to the National Family Health Survey (NFHS 5), 18.5 percent of the urban population does not have access to an improved sanitation facility, and 1.4 percent do not have access to an improved drinking water source. 

The private sector undoubtedly makes significant contributions to fill the existing gaps in healthcare service provision; however, several issues plague the efficiency, equity and quality of their services.

Urban Health: Existing Policies and Programmes in India

India’s focus on the comprehensive development of the urban health system is a recent phenomenon. The Tenth Plan observed that “Unlike the rural health services, there have been no efforts to provide well-planned and organized primary, secondary and tertiary care services in geographically delineated urban areas. As a result, in many areas, primary health facilities are not available; some of the existing institutions are underutilized, while there is overcrowding in most of the secondary and tertiary centres”. Responding to this reality, the National Urban Health Mission (NUHM) was launched in 2013 under the overarching umbrella of the National Health Mission (NHM).

The launch of NUHM was a decisive step taken by the Government of India, acknowledging the heterogeneous nature of communities in urban areas, which resulted in unique vulnerabilities and requirements and initiated systematic development of urban health systems across the country. NUHM provides a comprehensive framework for setting up urban health systems in different contexts and defines institutional mechanisms at the national, state, and district levels for implementation.

Under the National Urban Health Mission, every municipal corporation and town panchayat becomes a unit of health planning. The Mission provides flexibility to states/UTs to choose the model which suits the needs and capacities of states to best address the healthcare needs of the urban population, especially the urban poor. The broad framework of programme implementation proposes rationalizing the available human resources, improving access through communitised risk pooling mechanisms, and enhancing participation of community in planning and management of the health care service delivery by ensuring a community link volunteer such as ASHA (Accredited Social Health Activist) or Link Worker from other programs like ICDS, etc.

Empowerment of the community through awareness generation, whereby they can demand services from the Health System, is also an important area of emphasis under the NUHM. Urban health systems have an edge over their rural counterparts in the availability of human resources for health, as the urban density of doctors is nearly four times that in rural areas and three times higher in the case of nurses. However, the outcome of NUHM has not been uniform across urban areas in the country. 

Although, the out-of-pocket expenditure (OOPE) as a percent of Total Health Expenditure has reduced from 64.2% in 2013-14 to 48.2% in 2018-19,  the average OOPE in government hospitals in urban areas is Rs. 326, while it is Rs. 1082 in private facilities. There also exist wide variations in OOPE across states in the country. The Government of India is implementing programmes such as the Free Drugs and Diagnostics initiative, PM-National Dialysis programme, etc., in rural and urban areas with the aim to reduce OOPE endured by families; However, It is imperative also to understand the context-specific direct and indirect costs which people in urban areas might have to spend like transportation to the health facility, loss of wages, etc., to understand the true extent of the financial burden endured while accessing healthcare services. 

The role of private healthcare providers in provisioning healthcare services in urban areas is another critical aspect which requires more focus. The private sector healthcare providers in urban areas consist of individual practitioners or small nursing homes that provide services focusing on curative care, in addition to medium-sized hospitals and large hospital chains targeting tertiary care. The private sector undoubtedly makes significant contributions to fill the existing gaps in healthcare service provision; however, several issues plague the efficiency, equity and quality of their services.

These include distributional inequalities of private providers in urban areas, a lack of uniform standards and protocols to which the private practitioners may adhere to, a need for quality assurance and cost control mechanisms for private providers, lack of implementation of the Clinical Establishment Act (CEA) in some states, leading to a regulatory vacuum, etc.

Although the 74^th Amendment of the Constitution places the healthcare system under local governance, its role in delivering healthcare in many states is almost negligible. In states like Kerala, decentralization under NUHM has resulted in the devolution of functions, funds, and functionaries to the ward level; some states in India have not reached this stage. Research shows that the weak capacity of ULBs is one of the major reasons for their sub-optimal involvement in planning and implementing health policies and programs.

It is in this context that the Government of India launched the Ayushman Bharat – Health and Wellness Centres (HWCs) in 2018, marking the shift of focus from selective to comprehensive primary healthcare. Under this program, the Government of India targets the conversion of 1.5 lakhs SHCs, PHCs, and UPHCs into Health and Wellness Centres by December 2022. Funds for converting UPHCs into UPHC-HWCs are also provided under recently launched schemes like Ayushman Bharat – Prime Minister’s Health Infrastructure Mission (PM-ABHIM) and the 15^th Finance Commission earmarked grants for local bodies. 

Universal Comprehensive Primary Health Care is planned to be provided through these Urban Health and Wellness Centres (Urban HWCs) and Polyclinics, in addition to dedicated funds for diagnostics in close collaboration with Urban Local Bodies. Another critical intervention is establishing cost-effective laboratory systems at the district level that provide rapid, reliable, and accurate test results, with defined upwards and downwards linkages.

These facilities will enable decentralized delivery of health care services closer to people, thereby increasing the reach of the public health system to the vulnerable and marginalized in urban areas. The Government of India is building the capacity of rural and urban local bodies to plan and implement the urban components envisaged under PM-ABHIM and the 15^th Finance Commission grants. This can bring revolutionary improvements in the governance of urban and rural health systems. 

A ‘one size fits all’ approach will not work for urban areas, as the requirements of residents residing in the same slum area may vary as they migrate to slums from different contexts and cultures.

Way Forward: 

Moving forward, the most crucial strategy to improve health outcomes in urban areas is understanding the dynamic and complex nature of health vulnerabilities experienced by the urban population. A ‘one size fits all’ approach will not work for urban areas, as the requirements of residents residing in the same slum area may vary as they migrate to slums from different contexts and cultures. In order to respond suitably and adequately to improve health outcomes, there is a need for a granular understanding of the vulnerable groups and the nature of their vulnerability. This strategy will pay huge dividends in improving the health of urban communities and will improve social inclusion. 

Strengthening communities’ involvement in the governance of urban health systems also requires enhanced focus. Community platforms like Mahila Arogya Samitis (MAS) in urban areas bring community members into the governance process through their participation in regular monitoring of health care services. This empowers communities to take ownership and hold the health system accountable for their needs. 

Strengthening convergence and collaboration between different departments in urban areas is another aspect that needs improvement. Implementation of vertical programs without integration into the existing health system results in duplication of efforts and resources and poses a sustainability issue. 

The ‘Framework of Implementation for NUHM’ emphasizes that the focus of the Mission is on the urban poor, which includes residents of listed and unlisted slums and vulnerable populations such as the homeless, rag-pickers, street children, rickshaw pullers, construction and brick and lime kiln workers, sex workers, and other temporary migrants. However, considering the efforts made by the government to ensure quality, affordability and availability of healthcare services in urban areas, it is time to move from the current targeted approach to a holistic approach. Additionally, following a targeted approach in the provision of services is not easy, given the dynamic and temporary nature of populations in urban areas.

With the exponential growth of the urban population, it is only rational to anticipate a parallel increase in the urban poor population in the coming years. The above mentioned approaches are not exhaustive; however, these could be used as a starting point in devising strategies. Effective knowledge-based health planning, implementation, monitoring, evaluation, and health governance are required at all levels to ensure equitable access, affordability, and quality of services provided at urban health facilities and to ensure equitable health outcomes in the dynamic and complex urban populations. 

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Tanya Spisbah, Director with Australia India Institute, Delhi is a renowned and influential expert on Australia-India relations, particularly with respect to health and sustainable development. A career diplomat with the Australian Department of Foreign Affairs and Trade for more than a decade, Ms. Spisbah served from 2014-17 at the Australian High Commission in New Delhi, specializing in health and technology diplomacy for inclusive, sustainable growth. She notably led the health agenda resulting in the Australian and Indian Prime Ministers exchanging an MoU for Health and Medicine, paving the way for cooperation on digital health.

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Addressing the Financial Crisis

“Universal health coverage is also about ensuring access to essential quality care and financial protection,” says Dr. Mahjour. It aids in enhancing people’s health at large and increasing their life expectancy. Under this, many countries are protected from epidemics and the risk of hunger. This paves a way for new jobs, enhanced economic growth, and gender equality.

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“We are moving into a bold era, defined by advanced medical technologies and artificial intelligence. But healthcare will always remain a human business”. For Dominic Asquith, British High Commissioner to India that is the crux of the current situation, but a razor-sharp competitive business in medical devices across the world has a different narrative because of market compulsions vis-a-vis human business.

India’s strong position on heart stents’ price regime triggered debate and the price war snowballed into tough positions and international players gaped with bewilderment. Many institutions and professional bodies flew into action and debated price structures while the country’s federal government unveiled its world’s largest health coverage scheme for millions, virtually creating a colossal potential in the health sector. If the government extends healthcare services to its 1.25 billion population as part of India’s Universal Health Coverage (UHC) agenda, it will be a challenge to devise ways to reduce catastrophic Out Of Pocket (OOP) expenditure on healthcare and ensure affordable access to essential healthcare for the entire population with the limited resource envelope.

Amid ongoing trading tussle between US and China, many apprehend that ripple effect will also percolate down in India as the latter is going ahead with its price regimes and its moves to bring down stent and knee implant devices had raised many eyebrows.

A section of media has reported that AdvaMed (Advanced Medical Technology Association)in its briefing memo for US Commerce Secretary and US Trade Representative last year had conveyed that “Made in India” scheme has been used by parts of the Indian government to justify protectionist measures such as import tariff hike sand preferential market access policies.

The Economist newspaper recently carried a write-up which quoted China Digital times, a California based website, that Chinese media had been advised to play down China’s global dominance in various technological sectors, known as “Made in China 2025”.Such developments indicate that India should also dial down the hype on “Made in India”.

The 2014 World Bank Report estimated the OOP spending on healthcare in India to be as high as 89%. India is the only country, out of the major world economies, where out-of-pocket expenses are increasing, despite a concurrent increase in public spending. This effectively means that more people are availing private healthcare services due to rising incomes or are forced to spend due to inadequate public expenditure.

Official sources say big schemes can be ensured with the help of Health Technology Assessment (HTA), which is a widely used methodology internationally for optimization of resource allocation in health. HTA is a method of evidence synthesis that considers aspects pertaining to clinical effectiveness, cost-effectiveness, social, ethical and legal implications of the use of “health technology” for healthcare intervention.

The Indian healthcare industry was valued at over USD 100 billion in 2016 and is expected to reach more than USD175 billion by 2020, resulting in a CAGR (Compound Annual Growth Rate) of 20%. The medical device industry is valued at USD 6 billion. The medical device industry was accorded the status of an independent industry in 2014. The medical device sector today is clearly small and indicates low penetration in the country.

“The path to realizing healthcare goals is complex, and various fundamental issues and challenges need to be addressed and solved holistically. Long-term plans need periodic policy and regulatory interventions to ensure fair conduct within the industry while providing the support needed for profitable and sustainable growth. These activities will enable the medical device industry to accelerate rapidly and play a key role in making India healthier and stronger.” Mr. Guljit Singh, Executive Chairman of SKP Business and Abby Pratt, Vice President for Global Strategy and Analysis at AdvaMed said in their forward of the study. AdvaMed had partnered last year with SKP to publish the study entitled – Medical Device Industry in India –the evolving landscape, opportunities, and challenges.

The study also examined various policies and regulations impacting the industry and attempts to make recommendations on the way forward from the perspective of different stakeholders.

The study made a slew of recommendations like cap trade margins and not price to the dealers, should be capped after a detailed evaluation of each medical device segment and the role of trade. Trade margins should be fixed differentially for different categories of devices, based on service requirements and role of distributors.

It says allow the dealers to compete with each other and provide a fair price to the hospitals based on the terms and conditions of services and payments. There is a need to work towards bundled payment models as used in many other countries to better align incentives for hospitals and their business models. Increase government healthcare spending as a percentage of GDP; India lags behind the other BRICS in this regard.

Adequate utilization of government infrastructure to reduce the cost to private players – PPP model could be an attractive alternative to explore. Specify certain quantities/ proportions of supply of different stents at lower prices to specified government agencies for use with underprivileged sections. It advocated to empower the Medical Technology Assessment Board (MTAB) to evaluate the model of tiered pricing as observed in the French healthcare ecosystem, wherein the NPPA caps the generic products and leaves the latest generation products with incremental value out of the ‘essentiality purview’.

The incremental value could be on account of efficacy, material used, ease of delivery and shortened recovery time. Various combinations are possible here such as: an increase in the number of tiers, allowing new introductions to be free of price intervention for a certain number of years. Identify priority medical devices and procedures that demonstrate the greatest need stemming from disease burden. MTAB, alongwith other regulators for medical devices, should ensure that there are minimum quality parameters – in terms of safety, clinical efficacy, and cost-effectiveness – for medical devices that get used in the public and private health system, such that long-term costs are lowered over a patient’s lifespan, with need for fewer hospital readmissions, lowered need for medication, and overall better health outcomes.

The report said factors such as changing demographics, rising life expectancy, growing incomes and public awareness have contributed to a higher demand for medical care. A more focused approach from the government, with increased public expenditure on health, greater utilization of technology, vibrant private sector participation, and continued innovation can transform the sector and move India closer to its goal of providing quality universal healthcare.

Some of the key issues faced by the Indian healthcare industry are evident: with India’s disease burden shifting from acute to chronic diseases, large number of the population continue to not have access to basic healthcare services. Public health infrastructures are poorly equipped to deal with this shift towards NCDs.

While the government and value chain participants are undertaking several steps to address these issues, they have been executed in silos. Medical service providers are not only inadequate but are also not evenly distributed across rural and urban areas. This shortfall occurs despite an increase in the number of medical colleges from 23 in 1947 to 398 in 2014. The quality and availability of healthcare deteriorate as one moves away from large urban centers to lower-tier towns and rural areas. The Indian medical device industry, the report found, is highly fragmented. Currently, these sectors are dominated by MNCs with 70-75% of the demand being met through imports.

Approximately 30% of the domestically manufactured devices are exported, in which the consumables and disposables segment has the largest share.

On a mix of technologies such as engineering, electronics, material sciences and information technology – innovation, capital and technology drive the industry. However, India has not been able to bridge the gap between investments, skilled resources, and innovation to fully capitalize on these opportunities. Numerous factors underlie the prevalence of higher imports in the country.

Some of these are: no clear comparative cost advantage in view of other emerging markets; policy issues like inverted duty structured do not help in creating a positive environment; lack of favorable policy and regulatory framework, the report, compiled last year said.

On segments, the study said, hearing aids and pacemakers form major part of patient aid segment and constitute 70% of the segment collectively. Most of the products are sourced from Australia, China, Ireland, Singapore, South Korea and US.

The medical disposables and consumables sector consists of products such as plastic syringes, blood bags and many others. This segment is dominated by domestic players in India due to its low technology requirements. Needles and syringes constitute majority of the sales. However, wound management products and medical apparels are the fastest growing products in this segment. The Indian implants segment has witnessed an encouraging growth rate of CAGR 25%.

With a healthy mix of both domestic companies and MNCs, this segment has witnessed intense competition between players due to strong pricing pressure. The domestic players have realized the market potential which demands customization and differentiated product quality. The equipment and instruments section is the largest segment of the medical device industry constituting nearly 54% of the segment and is dependent on imports.

MRI machines, CT scanners, ultrasound machines, dental drills, dental chairs, dental x-ray machines are some of the key products of this segment. It is dominated by MNCs like GE Healthcare, Philips Healthcare, Schiller Healthcare, Danaher Corporation, and Roche.

Drug-eluting stents and bare metal stents form a major part of the stents segment and constitute more than 70% of the segment collectively. Most products are sourced from US and Europe. While domestic companies are manufacturing cost-competitive products, they still face competition from international players on account of quality. Diagnostics segment is growing due to advanced technology being increasingly applied in medical procedures.

The report had said government initiatives control regulation and the new Public Procurement Policy- the Preferential Market Access – do not fully reflect this and has alarmed many industry participants.

A clear long-term vision and roadmap for the industry and predictability of policy would excite the industry. The government needs to provide policy support for both the supply and demand side of the medical device industry to successfully accelerate growth. Industry and government need to work together to improve awareness, access has made rapid progress in the last decade, but significantly lags behind other nations in availability and quality of equitable medical care and services for citizens.

This, in turn, presents an enormous opportunity given the large population, growing economic prosperity, and the disease burden. Major issues such as availability of adequate infrastructure, trained human resources, geographic spread, rapidly changing disease burden, and high/often catastrophic out of pocket expenditures are challenges that the government is keen to address, the report said.

The Indian government is committed to raise public expenditure on health to 2.5% of the GDP. Public and private sectors need to play equally important but different roles in bringing rapid change to the healthcare scenario in the coming decade.

Around opening up, FDI and infrastructure development are welcome initiatives that will enhance the ecosystem for investment. The Indian medical device industry appreciates government’s efforts to remove bureaucratic hurdles and improve the ease of doing business, but believes that additional steps can be taken to strengthen its approach.

The study identified challenges and said growth in the healthcare industry has been attractive. However, much more needs to be done. Despite the advent of private players and better government spending, most Indians can only afford and/or have access to basic healthcare. Hence, the path to universal healthcare coverage is challenging.

Some of the obstacles faced are – real estate prices and high capital costs limit the growth of delivery infrastructure; insufficient attention by policymakers and a complex tax regime are also responsible for the sector’s underdevelopment; the lack of a comprehensive policy and focus to develop the healthcare ecosystem; low penetration: the per capital medical device spending of USD 3 compared to USD 7 in China and USD 42 in Russia is significantly low.

Another study early this year – “Medical devices in India – an agenda to effective healthcare delivery” said to attract world’s top med-tech players to establish their research and development (R&D) operations in the country and to establish a firm footing in the global market, the Government needs to adopt a robust policy and regulatory framework. India can replicate some of the models being adopted by other nations that have succeeded in attracting leading medical players. The contents of this report are based on a study commissioned by AdvaMed and conducted by IQVIA on behalf of AdvaMed.

It said that the government can provide financial incentives in form of extended tax holidays or weighted tax reduction for R&D investments; boost local demand for medical devices by stepping up public healthcare spending which in-turn could catalyze investments in this sector. Further, the government should focus on creating an enabling regulatory landscape by creating a separate legislation system for medical devices.

The report said while, Medical Devices Rules 2017 is a welcome step towards regulating the medical devices sector, the setting up separate notified body and distinct legislation system for devices with a focus on the following could further boost growth of the industry like Grant product approvals; Instituting quality standards; Setting up monitoring mechanisms for devices; Expedite patent approval process for medical devices.

Medical devices form more than USD 200-billion global industry, which develops and manufactures essential healthcare equipment. The Indian industry is currently valued at USD 4.4 billion with about 700 medical device makers, India’s medical device market is currently the fourth-largest in Asia (after Japan, China and South Korea) and ranks among the world’s top 20.

Imports constitute a substantial part of the medical device market in India. An estimated 80% of India’s demand for medical devices is currently met by imports, nearly 30% of which are supplied by the US. Imported medical devices are often those that are critical, innovative and high-risk in nature – either life-saving or life-enabling, and therefore undergo rigorous testing. These complex, innovative devices are designed to address the growing expectations of India’s population in the country’s rapidly evolving healthcare system, this report said.

The medical device industry has been very encouraged by the Prime Minister’s recognition of the critical role of medical devices in addressing India’s healthcare challenges. The Adva Medwebsite says in general, we have a received a strong message from the government that they are interested in promoting the medical devices sector and creating an environment that fosters innovation. This is great news not only for manufacturers of medical devices but more importantly for patients who desperately need access to high quality yet affordable lifesaving and life-enhancing medical technologies.

The PM’s call to medical device manufacturers is a welcome recognition of this separate and important part of the healthcare system. Several of AdvaMed’s member companies have already established manufacturing units in India, and India is being increasingly viewed as an R&D base.

The website says, the medical device industry in India has grappled with challenges for several years around recognition and regulation. While the Global Medical Device Nomenclature (GMDN) lists more than 14,000 different product types, the current regime only regulates a relatively modest portion of these products.

Moreover, these devices/products are regulated as “drugs” under the Drugs and Cosmetics Act of 1940. This is problematic because medical devices are very different from drugs in terms of diversity, product development, patent structures, types of failures, scientific disciplines involved in assessing performance/efficacy.

In addition to the arbitrary application of the rules for drugs to medical devices, which hinders the development, quality of and access to medical devices, there is also a lack of predictability in the regulatory system. The industry is also concerned about the lack of standardization in line with global best practices.

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