Modicare: High on rhetoric, low on evidence

Modicare: High on rhetoric, low on evidence

We are surprised at the Comment by Richard Horton on Modi Government’s Ayushman Bharat (AB) (1) in The Lancet.

The component emphasized as Modicare is the National Health Protection Mission, an insurance scheme assuring free hospitalisation for 500 million persons. Modicare represents the incorporation and expansion of several Publicly Funded Health Insurance (PFHI) programmes already existing in over a dozen Indian states. There is abundant evidence that these PFHIs have failed to deliver financial protection for hospitalization, especially for the poor (2,3).

The private sector is receiving the bulk of the insurance money but fails to honour contractual terms that ensure access and guarantee cashless services (4). Healthcare under insurance has remained selective (5). ‘Gaming’ brought in by insurance is causing damage to the public delivery system (2). Modicare could make these problems bigger and accelerate commercialisation of healthcare at public expense. Its design is ill-suited to address the challenges of epidemiological transition. The Comment does not seem to have considered such evidence.

If the second component of AB, ‘Health and Wellness Centers’ builds on National Health Mission’s decade-long but incomplete efforts to strengthen primary health care and public health services, that would be a reason for cheer. This component would require an additional 2.5 billion USD annually, which has not been budgeted by Government.
By being dismissive of all past efforts and by lauding initiatives which either have poor evidential support or lack the required budgetary allocation, Horton could be trivialising the quest for UHC and in danger of appearing overtly partisan.

Sundararaman Thiagarajan, TK Sundari Ravindran, Amit Sengupta, Samir Garg and Sulakshana Nandi

1. Horton R. Offline: The new politics of health in India. Lancet [Internet]. 2018 [cited 2018 Sep 16];392:902. Available from:
2. Prinja S, Chauhan AS, Karan A, Kaur G, Kumar R. Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review. PLoS One [Internet]. 2017;12(2):e0170996. Available from:
3. Ranjan A, Dixit P, Mukhopadhyay I, Thiagarajan S. Effectiveness of government strategies for financial protection against costs of hospitalization Care in India. BMC Public Health [Internet]. 2018 [cited 2018 Jul 1];18. Available from:
4. Sen K, Roy SG, Kumar S, Narayana K, Priyadarshi A. Health Reforms and Utilization of Health Care in three states of India: Public health Prospects. Soc Med [Internet]. 2018 [cited 2018 Jun 25];12(1):108–21. Available from:
5. Dasgupta R, Nandi S, Kanungo K, Nundy M, Neog R. What the Good Doctor Said: A Critical Examination of Design Issues of the RSBY Through Provider Perspectives in Chhattisgarh, India. Soc Change. 2013;43(2):227–43.