Ayushman Bharat scheme will end up putting more emphasis on the viability of provision through the private sector rather than on reaching the most vulnerable with good quality healthcare
As was expected, Prime Minister Narendra Modi made an announcement on the Ayushman Bharat (AB) – National Health Protection Scheme (NHPS) — in his Independence Day speech. While earlier news reports suggested that the PM would launch the scheme from the ramparts of the Red Fort, it will now be launched on September 25, the birth anniversary of Deen Dayal Upadhyay.
In that sense, except for renaming the scheme as Pradhan Mantri Jan Arogya Abhiyan, what Modi said is similar to what the finance minister had said in his Budget speech six months ago. The re-naming of the scheme bringing in the reference to the Prime Minister is possibly confirmation that the Bharatiya Janata Party (BJP) hopes to ride on this as one of its major achievements in the run up to 2019.
Much has been written on the (un)desirability of an insurance-based model for achieving universal healthcare in India. Given the double burden that India faces of communicable and non-communicable diseases along with the high burden of out-of-pocket expenditure (a large part due to outpatient expenses), inadequate health infrastructure in many parts of the country and a poorly regulated and heterogeneous large private sector, many would argue that a more appropriate strategy would be one where public expenditure is enhanced to strengthen the public health system at all levels, from primary to tertiary.
While one component of the AB is setting up of health and wellness centres at the primary level, the budgets allocated are nowhere enough in comparison to the gaps that currently exist in human resources, infrastructure, medical supplies, etc.
From what the ministry and its officials have been putting out in the press and on social media, it seems that the energies over the past six months have been focused on trying to bring the state governments and private sector (hospitals and insurance companies) on board so that the scheme can be rolled out. Eight major states are yet to sign MoUs while the rest have chosen to implement the scheme through the ‘trust’-based model.
The associations of private hospitals have been complaining that the package rates are too low and the Indian Medical Association (IMA) is trying to negotiate on their behalf. It is becoming clearer that the private sector does not want to get onto this unless profits are guaranteed.
Experience of other countries, particularly the United States, shows that a model of health that is based on insurance provision is expensive with continuously escalating costs. In India too, for instance, in Chhattisgarh, the premiums have gone up from Rs 804 to Rs 1100 for a coverage for just Rs 50,000 in recently opened tenders under state scheme.
An insurance-based strategy at a smaller scale has already been tried through the Rashtriya Swasthya Bima Yojana (RSBY) as well as the number of state public health insurance schemes. The experience of these schemes has also thrown up a number of lessons, which the new NHPS does not seem to take account of.
First, the provision of insurance coverage for in-patient care through the RSBY did not succeed in reducing out-of-pocket expenditure. While the NHPS increases the insured amount, it is not clear how that in itself would solve the problem. It is found that the expenditure relates to transport, loss of wages, pre- and post-treatment costs, which are not covered by the insurance.
Second, the RSBY was also a targeted scheme (based on BPL lists) and it was found that many poor were excluded. While the socio-economic caste census (SECC) on which the NHPS is based is a relatively better method of ranking deprived households, the problem of arbitrary “caps” in coverage (40% in this case) remains and can be expected to cause inclusion and exclusion errors. Moreover, it is over seven years since the SECC has been conducted and these lists have not been updated.
Third, existing healthcare facilities are concentrated in urban areas and near the metropolitan cities making access to institutions inequitable. This is once again a problem that can only be exacerbated through excessive focus on insurance coverage.
Just because of its scale the NHPS has the potential to change the health landscape in India. While it is welcome that health is final making front page news and has captured political imagination, the worry is that this particular strategy ends up putting more emphasis on the viability of provision through the private sector rather than on reaching the neediest and the most vulnerable with good quality healthcare. Issues related to prevention as well as social determinants of health are totally out of the picture.(The author is a teacher at School of Liberal Studies, Ambedkar University Delhi. The views expressed are personal.)