It is unusual for a healthcare scheme to become one of the most talked about provisions of a Union budget. In the past, finance ministers have, at best, made cursory references to universal health coverage in their budget speeches. But while presenting the Union Budget for 2018-2109, Arun Jaitley broke this tradition when he introduced “the world’s largest government healthcare related programme”. He was talking about a new publicly-funded healthcare insurance scheme, the National Health Protection Scheme (NHPS). “Ten crore familes will get Rs 5 lakh per year to cover secondary and tertiary hospital expenses,” the finance minister said. Given that this amount is more than 16 times the Rs 30,000 provided to BPL families by the Rashtriya Swasthya Bima Yojana (RSBY), usually for secondary care, the insurance scheme announced in the budget does signal a significant departure in healthcare policy. But the NHPS’s success in providing universal health coverage will hinge on the adequacy of primary medical services — the Achilles heel of the country’s healthcare system.

In a country where a health crisis is often a precursor to financial catastrophe for the poor, the salience of a healthcare financing scheme cannot be overstated. But according to a study last year, in the international journal, Social Science Medicine, the RSBY did not lead to any significant reduction in out-of-pocket health expenses by its beneficiaries. The one strand running through the several reasons for this failure is that the country’s healthcare infrastructure is not up to the mark. According to the Union Ministry of Health and Family Welfare’s Rural Health Statistics (RHS) 2016 Report, the country has a 22 per cent shortfall in primary health centres (PHCs). More than 80 per cent of the posts of specialists in community health centres in rural India are vacant, according to the report. More than 40 per cent of the PHCs do not have ambulances to transport the critically ill to community and tertiary-care facilities. Primary and community health centres are crucial to needs of patients who do not require hospitalisation — tuberculosis patients, for example. The RSBY did not address their requirements. The NHPS, too, remains disconnected from primary healthcare.

A weak primary healthcare system could burden tertiary care. In other words, the NHPS could drain government resources, which could, in turn aggravate the neglect of primary healthcare facilities. The government intends to pay for the hospitalisation of the new scheme’s beneficiaries through “strategic purchasing” arrangements with private healthcare providers. But there are currently no protocols for diagnostic tests for the beneficiaries of publicly-funded insurance schemes — a well-known criticism of the RSBY was that private hospitals often took advantage of the insurance coverage of patients by prescribing unnecessary tests. The success of the NHPS will require the government to join several dots. On current evidence, it seems that it hasn’t thought the challenge through.