New Delhi: The Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a component under Ayushman Bharat launched by the government to support the economically weaker section (EWS) to avail of healthcare services. The PMJAY scheme was launched in September 2018 to provide health insurance coverage of ₹5 lakh to about 50 crore beneficiaries.

However, a detailed analysis of the PMJAY has shown that those most vulnerable – whether in terms of state communities or gender – have not been able to use it as well as the relatively better off. The analysis was published in Lancet Regional Health —South East Asia and done by researchers from Association for Socially Applicable Research (ASAR), Pune and Duke University School of Medicine, in the US. The study looked at the 2018–2022 period.

The study cited a 2021 national household survey that showed that awareness and enrolment levels were the lowest among households in the poorest 40% of the population. “Thus, overall, the scheme is failing to target the most vulnerable population,” it stated.

The vulnerable population groups, e.g. Scheduled Castes (SCs), Other Backward Classes (OBCs), the Islamic population, and families with children and elderly, have higher cases of Catastrophic Health Expenditure (CHE) a situation where health spending exceeds 10% of a household’s consumption expenditure. Also, the incidence of Impoverishing Health Expenditure (IHE) is higher in rural areas and poorer states compared to urban areas and wealthier states.

The inequities are reflected in the supply and utilisation of services under PMJAY. To assess equity in PMJAY’s supply-side components, the study measured the number and distribution of empanelled hospitals. Information about supply-side components like medical equipment, drugs, and health workforce was unavailable. To assess utilisation-side components of PMJAY, they measured claim volumes, claim values, and enrollment rates.

The report states that states with higher poverty headcounts and disease burdens have a higher need for PMJAY and vice versa. However, the utilisation of claim volume and value is higher in states with lesser needs, e.g. Kerala and Himachal Pradesh, and lesser in states with higher requirements, like Bihar, Madhya Pradesh, Uttar Pradesh, and Assam. “This discrepancy in need vs utilisation is due to poor supply-side factors, including a low number of empanelled hospitals, an inefficient beneficiary identification system, and weak health governance in states with greater poverty and disease burdens. A similar pattern is seen at the district level, where socio-economically backward districts (also known as aspirational districts) have lower beneficiary identification rates, the total number of claims, and total claim amounts than non-aspirational districts. The majority of aspirational districts are located in Jharkhand, Orissa, and Chhattisgarh,” the report states.

The report further states that enrollment under the scheme is almost equal for males (50.8%) and females (49.2%) nationally. However, the total number (volume) and value of claims are higher for males than females (51.5% and 56.4% vs 48.5% and 43.6%, respectively). Out of the top 50 procedures in PMJAY, 60% of procedures are utilised more by males and 30% are utilised more by females.

SC and ST groups are considered the two most vulnerable in India and are, therefore, eligible for PMJAY. “Overall, these groups comprise approximately 28% of India’s population. However, there is little information to understand the utilisation. At the national level, SC and ST populations have contributed to only 5% and 2% of private hospital admissions, respectively, since the scheme’s inception,” the report states.

The report concludes that PMJAY has been updated in several aspects, including a larger population, services and cost coverages, awareness creation, and monitoring and evaluation. However, it still lags in binding domains like equity in supply and utilisation, targeting vulnerable populations, including outpatient coverage, and dynamic cost coverage. “The inequitable supply and utilisation affect the most vulnerable groups. It risks creating a spiral where the most deprived classes can fall into further deprivation. PMJAY should work on the above-discussed shortfalls, which will need an increase in supply-response regarding healthcare infrastructure and services and an overall increment in GHE,” it states.

Courtesy: Newsclick

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Indian has a shortage of an estimated 600,000 doctors and 2 million nurses, say the findings of a study by the Center for Disease Dynamic, Dynamics, Economic and Policy (CDDEP) in the US. This was reported by scientists who seemed to have found that the lack of proper training in administering antibiotics is preventing patients from accessing affordable life-saving drugs.
 
CDDEP produces “independent, multidisciplinary research to advance the health and wellbeing of human populations in the United States and around the world.”

Limited government spending for health services contribute to high medical costs for patients, reported the study by the CDDEP.

The health expenditure in India is largely out of pocket, as much as a staggering 65%, and such expenditures push more than 57 million people into poverty each year.

To identify key barriers in access to antibiotics in low and middle income countries, the researchers at CDDEP conducted stakeholder interviews in Uganda, India and Germany apart from literature reviews.

Gaps galore
There is a glaring gap in the international standards of health as defined by the World Health Organization (WHO) and as is practised in India. For example, though the WHO prescribes a doctor to patient ratio of 1:1000, in India, the study found that there is one doctor to every 10, 189 people. This implies a deficit of more than six lakh doctors. The nurse to patient ratio is 1:483 and has a glaring shortage of two million nurses!

Highlighting the accessibility or procurement of drugs as the primary challenge, Ramanan Laxminarayan, director at CDDEP said, “Lack of access to antibiotics kills more people currently than does antibiotic resistance, but we have not had a good handle on why these barriers are created.”

Recommendations of CDDEP study
The recommendations of the study say, “Interventions to improve access to antibiotics must take into account differences among countries. Healthcare institutions, both public and private, and regulatory, procurement, and supply chain systems need to meet users’ expectations and clinical best practices.”

It added that healthcare in many Low-Middle Income countries “requires fundamental changes, more government spending, and better regulation.” The study recommended that countries’ long-term visions should include plans to incorporate access to essential antibiotics into priority programs, such as infectious disease surveillance, HIV, Tuberculosis, malaria, and mother and child health programs, where efficient supply chains have already been established.

Emphasising the importance of National Health insurance schemes, it said, “National health insurance schemes can reduce out-of-pocket payments by patients, adequately fund health ministries, and dedicate funding for essential medicines, including antibiotics.”
“Ultimately, rising antibiotic resistance may be the biggest barrier of all. If resistance renders treatments ineffective, efforts to improve access to antibiotics will be futile, and the consequences will be felt worldwide. Antibiotic stewardship and infection prevention must therefore be pursued alongside improvements in access. All stakeholders—international bodies, government leaders, health and agriculture ministries, patients and medical practitioners, farmers and veterinarians, academia, and the pharmaceutical industry— must slow the emergence of resistance to existing antibiotics to ensure affordability and access everywhere,” the study concluded.

India’s spending
However, India’s public health expenditure is amongst the lowest in the world at 1.02% of its GDP in 2015 (a figure that has remained unchanged since 2009). This figure is lower than most low income countries.

The equivalent proportion of GDP spent on health in the Maldives is 9.4%, in Sri Lanka 1.6%, in Bhutan 2.5% and in Thailand 2.9% as per an IndiaSpend report.

Not surprisingly then, India has become the sixth biggest private spender on health among low-middle income countries. Out-of-pocket health expenditure pushed 55 million Indians into poverty in 2011-12.
 

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At least 71 children have died in the last 45 days at a government-operated district hospital in Bahraich in Uttar Pradesh, ANI reported. D. K. Singh, the hospital’s medical superintendent, confirmed the deaths, and told ANI, “A large number of children were admitted to the hospital and 71 died in the past 45 days. Children have died due to various diseases.” Singh also said that the hospital has 200 beds “but currently, 450 patients are admitted here. The workload is very high. We are trying our best to save as many lives as we can”. 

According to an ANI video, Singh said that 2,158 children were admitted to the hospital in August until September 16, and that 71 children died, due to various ailments, including hepatitis, meningitis, anaemia, and septicaemia.

“The incident comes a year after 60 infants died in Gorakhpur’s Baba Raghav Das (BRD) Medical College, allegedly due to lack of oxygen supply,” ANI reported, adding, “The hospital authorities, however, denied this claim and said that the infants died due to encephalitis.” In July 2018, The Wire (Hindi) reported that 1,049 children had died in six months at the BRD Medical College. 

Meanwhile, NDTV reported that UP Chief Minster Yogi Adityanath’s government has sounded a high alert after 84 people died due to a “mystery fever” in the past six weeks. The state government issued a press release confirming the outbreak, naming the affected districts as Bareilly, Budaun, Hardoi, Sitapur, Bahraich and Shahjahanpur. 
 

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Overall, there was a 6% rise in dependence on public healthcare for out-patients and 7% for in-patients over the decade ending 2014, said the Brookings report, which analysed National Sample Survey Office (NSSO) data over this period.
 
An in-patient is formally admitted for at least one night to a hospital, while an out-patient visits a hospital, clinic, or associated facility for diagnosis or treatment.
 
For out-patient care, 74.9% of ailing patients (who sought care) exclusively accessed a private facility in 2014, compared to 79.7% in 2004. The biggest decrease was seen among rural women, as we said. While 78.2% of them sought private care in 2004, 70.4% did in 2014.
 

Source: Brookings India, based on National Sample Survey Office data
 
In-patients depend less on the private sector than do out-patients, the data reveal.
 
The percentage of in-patients seeking public care increased from 42.3% in 2004 to 45.4% in 2014;  the percentage of rural women accessing public care rose from 45.1% in 2004 to 56.1% in 2014.
 

Source: Brookings India, based on National Sample Survey Office data
 
“The number of people seeking private healthcare, however, might be an underestimation, as NSSO surveyors are instructed to mark all those who went to both government and private facilities as “only going to government facilities,” said the Brookings report.
 
Indians spend eight times more in a private hospital than a government hospital, according to this analysis of National Health Accounts (NHA) 2013-14 data by The Hindu.
 
Quality of care biggest constraint for not accessing public hospitals
 
Despite the decline in exclusive dependence on private care, 29 of every 1,000 Indians pointed to the unsatisfactory quality of healthcare, the most commonly cited reason for not accessing a public hospital.
 
Long waiting periods at government health services appears to be an increasing bottleneck in seeking public care. In 2004, 6.8 of every 1,000 cited this as a reason for not using a public hospital; it rose to 18.6 in 2014.
 
Of 930,000 doctors in India, 11.4% (106,000) work for the government. This means there is one government doctor for every 11,528 people, according to the National Health Profile 2015, IndiaSpend reported in November 2016.
 
Public-health centers across India’s rural areas–25,308 in 29 states and seven union territories–are short of more than 3,000 doctors, the scarcity rising 200% (or tripling) over 10 years, IndiaSpend reported in February 2016.

Source: Brookings India
 
More people required medical care over a decade
 
The number of people not using medical services fell from 15.1 in every 1,000 in 2004 to 12.4 in 2014, which implies an 18% increase in Indians seeking some form of healthcare.
 
There was an increase, however, in the proportion of people not seeking services, as they felt their ailment wasn’t serious enough, and more women than men report not using healthcare due to the same reason–the gender gap has widened over the decade.
 
More Indian men are likely to be admitted to hospital during the last moments of life than women–62.5% to 37.5%, IndiaSpend reported in November 2016. For every 1,000 men whose death is certified by medical professionals, the corresponding figure for women is 600.

Source: Brookings India
 
The number of people not using healthcare due to financial reasons reduced from four of every 1,000 in 2004 to 0.7 in 2014, said the Brookings report, possibly a result of rising incomes or use of publicly funded health-insurance schemes implemented over the last 10 years by the central and state governments.
 
About 12% of the urban and 13% of the rural population got health insurance through the Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) or similar plans, IndiaSpend reported in July 2015.
 
(Saha is an MA Gender and Development student at Institute of Development Studies, University of Sussex.)

This article was firs published on India Spend
 
 

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