Ayushman Bharat scheme said to provide universal health care in India, hailed as one of the “world’s largest government sponsored healthcare scheme” came in news again with the death of a person in an Amethi hospital. The kins of the deceased alleged that he was denied facility on the grounds that the “Ayushman” card belonged to Uttar Pradesh Chief Minister (CM) Yogi and Prime Minister Modi, while the hospital in question was run by Congress. The hospital denied these allegations even as the controversy is still unfolding with Union Minister Smriti Irani who is contesting from Amethi seat, reacting to the incident and tweeting about it.
The Ayushman Bharat National Health protection scheme (AB-NHPS) was announced amid a lot of hype and fanfare by PM Modi in Jharkhand on August 2018. It was launched in September, later that year. It was announced, in the usual grandiosity characteristic of literally everything that the PM announces, that the scheme will provide a health cover of Rs. 5 lakhs as compared to the modest cover provided by existing Rashtriya Swasthya Bima Yojana (RSBY) which provides a cover of Rs. 30,000. The Ayushman Bharat scheme is said to target over 10 crore Indian families comprising 8.03 crore rural families and 2.33 crore urban families.
The Ayushman Bharat scheme, later renamed as Prime Minister Jan Arogya Yojana (PMJAY) will subsume the existing RSBY. Some key aspects of the scheme are that there is no enrolment process and it is based on entitlement. Hospitals need to be empanelled in order to implement the scheme. Each empanelled hospital should have an “Ayushman Mitra” whose role will be to help those who visit the hospital navigate the facilities. Another component being access to Health and Wellness Center (HWCs) at primary level and financial protection.
However, the scheme missed the point at many levels. A Crisil report says that despite “sustained focus” on core health infrastructure, an overwhelming percentage of around 55 percent of country’s households don’t access government’s healthcare facilities because of perceived “poor quality of care.”
As rightly commented by a life sciences and healthcare expert Sheetal Ranganathan, this scheme which is pro-private insurance market, is overwhelmingly missing the voices of the people it intends to cater. In her essay titled “National Health Protection Scheme will not help its intended beneficiaries” she points out that majority in India, especially the rural areas don’t report sickness unless rendered inactive to work and earn, either by injury or the flare up of a chronic condition. This, in fact is common knowledge too. Going to a health center for minor treatments implies missing a day’s wage, a condition many in the rural parts of India can’t afford.
Moreover, that in rural India health is not a matter of choice. The scheme completely misses the point when it does not take into account the chronic conditions that people suffer from.
No matter which state the poor or deprived households may belong to, the epidemiological profile of the households will mirror each other At present, the top ailments that add the maximum burden of disease in the poorest states ( EAG or Empowered Action Group states ) include ischaemic heart diseases, lower respiratory tract infections such as bronchitis and asthma, chronic obstructive pulmonary disorder, tuberculosis and diarrhoea. Right now, these are the diseases adding the burden of maximum Out Of Pocket (OOP) expenditure to rural households. Hence in as many as 80 percent cases, the OOP expenditure of the patients within this strata depend on outpatient clinics, which require day to day diagnosis, and do not come under the ambit of NHPS.
The scheme includes hospitalization and surgical intervention, which though being an important aspect, is disconnected from this reality of the rural India.
The scheme demands that in order for its success or outreach, the reasons for the failure of RSBY should be carefully studied. For example, a study done in West Bengal’s five backward districts, Murshidabad, Malda, Dakshin Dinajpur, Uttar Dinajpur and Jalpaiguri reported that the preference for RSBY empanelled hospitals was low, the distribution of the empanelled hospitals uneven and there is a clear urban bias in the empanelment.
The National Family Health Survey (NFHS), 2016 indicated that apart from the perceived poor level of care being the topmost reason for households not accessing government facilities, the second surmounting reason was that there was no nearby facility, which is the harsh reality of rural healthcare in India. This is to say that PMJAY is marred with both, problems of accessibility and uneven empanelment.
A Center for Policy Research (CPR) report argued that the fact of the scheme being oriented towards insurance, makes it more likely to suffer from either over or under treatment, citing the example that though the treatment may be obtained by inserting a stent, the medical experts can suggest a bypass because it will be more expensive, as has been the experience with RSBY. Moreover, if the hospitals sense that there is not much profit, they may not enrol in the scheme at all. Or they can turn patients away. When the price is too high, the hospital will try to convince the patients for unnecessary expenditure, a stark case in point being that of mass hysterectomies under RSBY following such erroneous pricing.
The report highlights that good medical care requires massive investments in adaptive price settings, legislation, third-party monitoring, quality improvements in public sector hospitals and ultimately significant investments in skilled capacity. It is only right to expect that there should be an increasing government intervention in these areas, rather than its withdrawal.
However, the scheme has no concrete mechanisms to ensure any form of accountability and places the burden of study or research on local NGOs. The success of a scheme that has been panned out at such a level with ambitious targets and shows the intention to benefit a large section of the poor and deprived, depends on rigorous and thorough monitoring, analysis and research. It requires that the government studies the failures of the previous schemes. It also requires that the trust of the rural people be won over through facilitation of access and advocacy. None of these has been done in the case. Increasingly, even during the course of the research for this article, it was found that the voices were mainly of private insurance companies which are promising to provide good and efficient services at cheap prices, there are barely any voices of people sharing their experiences with the scheme. Unfortunately this seems like another high soaring promise that’s likely to fall flat on its face.