The National Health Protection Mission is the Government of India's program intended to provide health care access to the economically backward and weaker sections of the society, who as a case, have so far been neglected. It represents a quantum leap towards universal health care. The NHPM insurance program is designed with patient-centric features like the cover for pre-existing diseases, portability of insurance cover, and provision for cashless treatment and includes pre and post hospitalization expenses to varying degrees.

As with any scheme of the scale of NHPM, success will depend on execution of the scheme. The plan is to integrate and merge the NHPM with existing schemes such as Rashtriya Swasthya Bima Yojana (RSBY) and different state-level health insurance schemes, and the mechanics of how this will be done smoothly without negative impact is important. While the basic contours of these schemes are similar, there is one aspect which makes NHPM fundamentally different from these schemes. RSBY or any state insurance schemes are all enrollment based schemes whereas NHPM is an entitlement scheme. Hence, if you fall under the beneficiary list, then you are automatically covered under NHPM. The NHPM will use the 2011 socio-economic census data to identify beneficiaries of the scheme. NHPM implementation strategy draws heavily from these existing models and proposes two models of implementation which are as follows:-.

  • Trust Model - An independent, not-for-profit body to be formed to implement the scheme
  • Insurance Company managing the scheme.

Some of the other vital attributes which will be critical for the success of the scheme in both the models above are the Governance Structure, Information Technology System, and Funding modalities. The government has indicated the planned governance structure which will oversee the entire scheme. It is proposed that there will be an Ayushman Bharat-National Health Protection Mission Council (AB-NHPMC) which will be a GST style council wherein there will be representation from both state and the center and will be chaired by union minister for Ministry of Health and Family Welfare (MoHFW). The responsibility of the council is to guide the future policy direction of the scheme and coordinate between states and the central government for effective implementation.

Officials from various authorities will jointly chair Ayushman Bharat-National Health Protection Mission Governing Board (AB-NHPMGB) which will be the governing board. National Health Agency (NHA), the agency is formed to provide overall vision and stewardship for design, roll-out, implementation, and management of AB-NHPM. The agency has been registered as a Society. NHA will be headed by Dr. Indu Bhushan, CEO of the level of Secretary / Additional Secretary to the Government of India.

The role of big data in a scheme like NHPM is critical to ensure that the scheme is implemented and benefiting the citizens as intended. Hence, along with NITI Aayog, the governing body would work to create a flexible, modular and scalable IT platform which will be used to track the KPI's of the scheme. The platform will also enable detection of any frauds/misuse/abuse of the scheme by any stakeholder. In cases of disputes, a grievance redressal mechanism is also being created to ensure fair resolution.

Funding for the NHPS scheme is another critical attribute that will determine its success. In the last few months, there has been ample speculation about the true cost of the scheme and how the government will fund it. When announcing the scheme, the government stated that about INR 100 billion would be provided for setting up technology systems and verifying beneficiaries. The initial grant will also be used to pay premiums in states that are implementing the scheme through the insurance model. GoI has given assurances that it will increase the same as and when required. Government plans to merge existing State health schemes with NHPM in which central government will bear 60% of the cost while states are to bear 40%. Funds transfer from central government to state health agencies will be done directly through an escrow account. The medical treatment package rates were supposed to be determined in consultation with the stakeholders and many rates have been published. Although the GoI states that the package rates proposed are fair and competitive, the healthcare delivery and the insurance players believe that the rates are too low and will not cover their costs. They believe that the low rates will compromise the quality of care and will defeat the purpose of the entire scheme.

NHPM undoubtedly has the potential to be a game changer for the Indian Healthcare sector. The coverage both in terms of people covered, treatments insured and sum assured are substantial. The Government is very clearly demonstrating the will and intent, and the concerned departments are working rapidly to roll out the scheme.

While the government has a laudable vision and objectives, the implementation approach has not been very consultative or accommodative. The premium amounts and the procedure costs proposed in the draft MoU shared with the states seem too low and may not be sustainable for the insurance players, industry and hospitals. Most insurance players did not participate in the scheme due to profitability concerns; hence most states opted for the Trust model. The governance structure will have to be made nimble to ensure there is no delay in resolving any issues or disputes and the patient does not suffer due to process or procedural matters. The government will have to ensure that the entire system right from admission to discharge is hassle-free for the patient and all the necessary information is provided beforehand. The implementation guidelines will also have to ensure that there is no abuse/misuse of this scheme by any stakeholder. This has been one of the major reasons for previous center/state insurance schemes being less effective than intended.

We hope that the pilots being rolled out from 25 September will be used well to study all aspects thoroughly and find effective solutions for the full national rollout. The critical task for the government is to make sure that it can deliver what it has promised. As with all schemes of this scale, the effectiveness of the scheme will depend on a collaborative effort by all the stakeholders working in tandem for a common goal, i.e. Make India Healthy.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.