1. The poor are the primary beneficiaries of this scheme

Modicare’ s predecessor, the government-run health insurance programme Rashtriya Swasthya Bima Yojana (RSBY), covered only those identified in the national census as below the World Bank-defined ‘poverty line’ of $1.90 per day. Under Modicare, coverage criteria will expand to include identified occupational categories of urban workers’ and their families.

2. The scheme covers secondary and tertiary care only

There are approximately 1,500 secondary and tertiary care procedures nominated in the package of services covered under the scheme.

3. Responsibility for financing the scheme will be shared between the Central and the State governments

Purchasing will occur through a State-run trust fund or a market-driven tendering process. The States will be given flexibility over the financial administration of the scheme. 

4. Beneficiaries can avail benefits in both public and empanelled private facilities

States will be given flexibility over choice of care providers and means of purchasing and procurement.

5. The Scheme will pioneer the use of a novel digital information capture system

Utilising India’s biometric ID scheme, ‘Aadhar’ identification cards will be used to capture details of enrolment, claims and reimbursement activity in each State.

The rollout of such an ambitious scheme in a country as large and diverse as India faces challenges, including the identification of and outreach to beneficiaries; putting in place adequate governance and regulatory mechanisms to reduce fraud and low value care; and making sure finances allocated to provide for the scheme match local need.

Ensuring the delivery of high quality of care will perhaps be the most important challenge to address, given India’s recent ranking in terms of quality and accessibility of healthcare in the Lancets’ Global Burden of Disease study.

Nevertheless, Modicare represents a unique opportunity to provide access to healthcare to a population that sorely needs it, moving India one step closer to Universal Health Coverage and bridging economic, gender and social divides.

The scheme is due to launch next week on 25 September.

My colleagues Dr Katharina Hauck, Dr Ranjeeta Thomas and I are working on an iDSI project where we take the position that an important form of HSS focuses on service delivery ‘platforms’. These platforms can take many forms, such as a network of community nurses, a health centre, or even a hospital. Their common feature is that the delivery of a range of services depends to some extent on the platform. For example, a local health centre might provide antenatal maternity services, routine child health and vaccination programmes, and a variety of other ambulatory services.

The costs and effectiveness of each of those services are likely to be influenced by how well the health centre (the platform) functions as a whole. As a result, the services that use the platform are to some extent interdependent.
Conventional approaches towards the evaluation of health services consider treatments independently. They assume that the costs and benefits of a treatment remain unchanged whatever the characteristics of the platform, and are not associated with those of any other treatments that use the platform. Yet it is clear that both costs and benefits – but particularly costs – often depend heavily on how well a delivery platform is functioning and what other services are relying on the platform’s resources.

Our research models three types of investments in HSS that focus on delivery platforms. The first type looks at an existing platform and examines whether additional funds should be spent on improving the overall functioning of the platform or expanding the range/volume of services it supports. Using the funds for HSS will improve the quality (or reduce the costs) of existing services but will to some extent reduce the scope for introducing new services. This trade-off is at the core of many HSS decisions and we show how it can be addressed analytically.

It is often the case that a platform is unable to function as well as it should because of some physical constraint, such as limited human resource capacity. For example, a hospital may be unable to deliver some highly cost-effective treatments because of a shortage of medical personnel. The second type of HSS therefore examines the benefits of removing such constraints by investing funds in the right way, here by the hiring of additional medical personnel. Again, such actions will come with a cost, especially if the new ability to focus on more cost-effective treatments means sacrificing lower value treatments that are currently provided by the platform. The key policy decision is whether the costs of removing the constraint are outweighed by the benefits.

The third type of HSS is the consideration of an entirely new platform, often to affect a radical new way of delivering a treatment. An example might be the creation of a home-based testing programme for HIV/AIDS that relies on a new network of community health workers to test people in their homes, as an alternative to the current system of opportunistic testing at clinics. The decision whether or not to proceed with this option may depend on what other services could be delivered by the community workers, such as testing for hypertension, diabetes or tuberculosis, to make the home-visit worthwhile.

Our research therefore examines the trade-off between HSS and expansion of treatment coverage that is often encountered and has many policy implications concerning the nature and timing of health system reforms. We were excited to present our initial findings at HTAsia Link 2018 and look forward to publishing as the work develops.

Just days ago, Bill Gates had visited the country to meet with prime minister Nadendra Modi, where the multibillion dollar philanthropist commended the PM on his efforts to improve the country’s population health. Indeed, Gates followed up his visit with a guest editorial in the Times of India, reflecting on his week of meetings in the capital and history of collaboration in India, stating that “With the right investment in India’s economy and India’s people, what lies ahead will be even more impressive”. Is it a coincidence that the PM waited until Gates had left the country before announcing cuts to the country’s largest public health program? I think not.

Reuters further reports that ‘officials familiar with the plan said the finance ministry reduced planned funding because of other spending priorities and because of state governments’ poor track record of spending the health budgets they’ve been allotted in the past’. This news is not new, and indeed an analysis by India Spend of 2017 Reserve Bank of India data on state budgets released in July this year, reported that nine of India’s poorest states spent less money than was allocated to them, and that these same states had the poorest performance indicators in the country.

I wrote a blog when the India Spend analysis was released in July this year, titled ‘More money does not mean more health’. In this blog I highlighted that system inefficiencies needed to be effectively addressed if countries, and states in the case of India, are to adequately utilise resources to improve health outcomes. While few would argue against the notion that India will not come close to achieving its ambition of achieving universal health coverage (UHC) with the current health spend of 1.4%GDP, one of the lowest spends globally, the notion that more money does not guarantee more health may come as a surprise to some.

We know from global surveillance data that health expenditure is rising in most countries across the world, yet figures released by the OECD reveal that a considerable proportion of this expenditure has little to no impact on improving people’s health. This is consistent with a 2010 WHO analysis which concluded that 20-40% of healthcare spending globally is wasted. This tells us that when the right systems are not in place to spend money wisely, effectively implement policy decisions, and govern their deployment.

So is the government of India justified in not increasing the budget allocated for health and raising the expenditure from the current 1.4% GDP? The answer is no. Unless more money is invested into the Indian health system to meet the growing demands of the 1.3bn strong population, the country will never realise its ambition of providing UHC. Consider the counterfactual – if investment in health stays stable or drops, are the population health indicators likely to improve? The latest Human Development Index, released in 2016 saw India slip to a rank of 131 out of a possible 188 countries in the world, behind neighbours Sri Lanka and the Maldives. If drastic action to rectify falling health indicators is not taken, evidenced by a stronger financial and practical commitment to health, the wellbeing of the population will continue to slide backwards.

Strong strategic planning and support should be undertaken to complement increased spending to ensure that additional funds are adequately absorbed and spent wisely. Such planning to not only spend more money, but spend it better is essential to maximise the value of every rupee spent, and ultimately improve the health of the population.

The key messages outlined in the earlier blog are highlighted here again, as follows:

• An important determinant of success or failure of Indian states to improve their health indicators will be the strength of system-wide mechanisms to engage in effective priority setting of resources and govern their deployment.
• Effective uptake of resource allocation decisions requires a system able to deliver and strong governance mechanisms to ensure that policies are properly implemented.
• Evidence-based priority setting of resources is important to maximise health gains made within the constraints of a finite budget.
• Without robust surveillance and governance mechanisms, the value of effective priority setting is severely diminished.
• Ensuring an adequate number of well-trained and reasonably paid health professionals with access to necessary equipment and infrastructure is critical to ensure a fit for purpose delivery system and address supply-side inefficiencies.

Our Impact

The second feature of the new website that we would like to introduce is the ‘Our Impact’ section of the site – which focuses on country specific work that ranges from developing quality standards to building capacity for health technology assessments.

Use the interactive map to explore the in-country projects that we are supporting – clicking on the country will take you to a page that highlights what work is being conducted and who we are partnering with to enable better healthcare decisions.

Click on South Africa and you will see we are working with our core partner PRICELESS SA (Priority Cost Effective Lessons for System Strengthening South Africa) a research unit based at Wits University School of Public Health, to develop capacity to undertake and use evidence provided by Health Technology Assessments to better inform government decisions on healthcare.

We’ve been working in South-East Asia for a number of years to bring about improvements to healthcare systems and policies. iDSI core partner HITAP (Health Intervention and Technology Assessment Programme) who are based in Thailand lead on much of this work. Our involvement in Vietnam has helped to to embed HTA evidence into designing a safer public health care system, and to improve hospital quality in key disease areas.

“The collaboration with iDSI has led to policy change and has been of great value to us in Vietnam. I appreciate the commitment shown by iDSI in supporting Vietnam to use evidence to inform decision-making in health.”

– Prof Pham Le Tuan, Vice Minister of Health in Vietnam

Find out more about our work in low and middle income countries by exploring the map here.

iDSI Knowledge Gateway

You can also search the iDSI Knowledge Gateway for specific country work using the ‘country focus’ search filter. For example you can view the documents related to our work in Thailand here. The iDSI Knowledge Gateway is an Open Access platform: providing decision makers within health on a global scale with free access to the tools and information they need to make better informed decisions to improve healthcare.

Stay up to date as we post about more of the new features on the website: follow us at @idsihealth and sign up for our newsletter using the form in the right hand side bar.

Throughout this week we will be posting blogs that highlight new features of the website, starting with our six key themes:

• Tackling healthcare challenges
• Strengthening health systems and institutions
• Generating and using evidence
• Smart purchasing for UHC
• Value for money for sustainable development
• Measuring impact

Our key themes represent iDSI’s approach and principles in supporting low and middle income countries to make better informed decisions about their healthcare spending and policies. By publishing both our technical content and blog posts under a key theme we hope to present our work in an organised and discoverable manner.

The six key themes are introduced under the ‘What we do’ section of the site, with a summary introducing the theme. Related posts are displayed under a drop-down box.

iDSI Knowledge Gateway

In addition to our website we are proud to introduce the iDSI Knowledge Gateway. We have moved all of our technical documents and knowledge products to a new space on the F1000Research website, under the same six key themes. F1000Research are an Open Access publisher and services provider for the life sciences community – the perfect place to host our outputs so they can be easily discovered and accessed by those looking for technical support to inform decisions made within healthcare.

Browse our content on the iDSI Knowledge Gateway here: https://f1000research.com/gateways/iDSI and share with your colleagues!

Stay up to date as we post about more of the new features on the website: follow us at @idsihealth and sign up for our newsletter using the form in the right hand side bar.

According to an IndiaSpend analysis of 2017 Reserve Bank of India data on state budgets, nine of India’s poorest states (48% of the population) account for 75% of under-five deaths and 62% of maternal deaths. The Central Government recognised these nine states as ‘high-focus’ as they were performing poorly in various indicators and allocated additional resources to them to improve health indicators. However, these ‘high-focus’ states spent less money than was allocated to them and indicators did not improve.

A growing number of LMIC are transitioning from development assistance in health towards increased domestic expenditure. An important determinant of success or failure will be the strength of system-wide mechanisms to engage in effective priority setting of resources and govern their deployment. India is not alone in the problem of absorbing finances allocated for health, a recent WHO report similarly described an underspend of 20-40% of money allocated to heath in Sub Saharan African countries. We know from global surveillance data that health expenditure is rising in most countries across the world, yet startling figures recently released by the OECD reveal that a considerable proportion of this expenditure has little to no impact on improving people’s health. This is consistent with a 2010 WHO analysis which concluded that 20-40% of healthcare spending globally is wasted.

Improving the ability of ‘high focus’ states in India to adequately absorb allocated funds will require robust mechanisms, to both engage in effective priority setting and ensure system readiness for implementation.

The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, will be critical in strengthening the Indian healthcare system.

The government of India is set to establish a Medical Technology Assessment Board (MTAB). The MTAB will evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system, and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process for healthcare decision making in India, towards the ultimate goal of achieving UHC. This formidable task will be crucial if States are to be empowered to adequately absorb and spend all funds allocated to them by the Central government to maximise health gains.

However, engaging in effective priory setting is only half the battle. Effective uptake of resource allocation decisions requires a system able to deliver and strong governance mechanisms to ensure that policies are properly implemented. Since moving into upper middle income status, the Indian government has made valiant efforts to strengthen the highly complex and fragmented health system. This is best evidenced through programs such as Rashtriya Swasthya Bima Yoganda (RSBY): the world’s largest social insurance program for those below the poverty line, which provides around 1000 secondary care services to registered card holders free at the point of delivery. However, the efficacy of such a program is severely impeded within the context of scant governance and regulation. Within months of the introduction of RSBY, stories began to emerge of profiteering clinicians cashing in on the capitation payment system by performing hysterectomies on whole villages of women. A largely unregulated and private-dominated care system means there is limited clinical surveillance data to ensure appropriate care provision and validate rebate charges. Without robust governance mechanisms, the value of effective priority setting is severely diminished. The importance of supply-side insufficiencies should also not be overlooked. Ensuring an adequate number of well-trained and reasonably paid health professionals with access to necessary equipment and infrastructure is critical to ensure a fit for purpose delivery system.

More money does not mean more health when the right systems are not in place to spend that money wisely, effectively implement policy decisions, and govern their deployment. It is the duty of the global health community to rise to the challenge to support policymakers across the world. Helping them to spend their money better to fully absorb available resources will maximise the value of every rupee or dollar spent, and ensure that adequate governance mechanisms are in place to protect these finite resources against waste.