Ayushman Bharat, India’s cashless healthcare plan for half a billion people living in poverty, turned one on 23 September.
Also known as the Pradhan Mantri Jan Arogya Yojana, or PMJAY, Ayushman Bharat has a big task and many challenges ahead of it. In an address at the Ayushman Bharat Arogya Manthan in the capital on 1 October, Prime Minister Narendra Modi said the first year of the scheme has been one of sankalp (action), samarpan (devotion) and seekh (learning).
Here’s a look at what the National Health Authority (NHA) — which runs Ayushman Bharat — has done so far, some of the challenges, and what else needs to be done to achieve the programme vision of offering “financial protection against catastrophic health expenditure” on the one hand and making quality healthcare accessible to all.
About the scheme
On 23 September 2018, the Government of India (GoI) launched an ambitious health insurance programme: Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana. Under this programme, annual health insurance of up to Rs 5 lakh is to be provided to every family below the poverty line, irrespective of their size.
The programme’s mission is to cover 100 million such families (40 percent of the Indian population), a bold step towards universal health coverage and preventing out-of-pocket expenditure among the poor.
Ayushman Bharat is a centrally-sponsored programme, but the implementation is at the state-level, which allows states to make any necessary tweaks to match the scheme with their ongoing social insurance programmes.
The Indian public health delivery system has traditionally been weak and overburdened, which means that the poorest of the poor often have to live with disease if they fall sick, or spend beyond their capacity on private care.
To prevent such catastrophic expenditure and distress financing which could push these families into further debt, Ayushman Bharat came as a ray of hope for this section of the population.
Nuts and bolts
The programme was designed to offer 1,393 procedures free of cost in empanelled public and private healthcare facilities across 24 specialisations. For these procedures, the programme has prepared rates to estimate the amount to be reimbursed to each hospital by the appointed insurance agencies or societies based on the number of health services delivered under the programme. Besides this, the government has also made provisions to incentivise high-performing hospitals in terms of quality and patient safety.
The second tier of the programme involves creating 150,000 health and wellness centres (HWCs) to provide comprehensive universal health care. The goal of these wellness centres is to link the community with secondary and tertiary care hospitals for screening, referrals, and creating awareness. Besides this, these HWCs are supposed to cover maternal and child health services, free essential drugs, non-communicable diseases and diagnostic services.
In an annual report released by the NHA, which runs the programme, Union health minister Dr Harsh Vardhan wrote that more than 10 crore e-cards (for health insurance) were issued and Rs 7,490 crore worth of treatments pre-authorised in just 365 days. This amounts to just over Rs 16,000 per person: much lower than the Rs 5 lakh limit per family under this programme.
Going by the data, it is apparent that the health insurance scheme is helping millions reduce their expenditure on health. But the burden has not been lifted. Instead, it has shifted to the Indian government’s shoulders, which is already facing challenges in meeting the needs of the population.
This brings us to an often overlooked problem with the scheme: currently, government is spending only 1.15 percent of the gross domestic product or GDP (with plans to increase this to 2.5 percent of GDP by 2025) on health and most of it is for curative services as compared to preventive services. By way of comparison, the US spent 17.9 percent of GDP on healthcare in 2017.
India is a developing country and as it enters into a better economic zone, the burden of lifestyle diseases such as diabetes and heart disease is increasing while hospitals are already burdened with treating communicable diseases such as tuberculosis and malaria.
Despite the HWCs including non-communicable diseases in comprehensive care, the loopholes in the basic infrastructure and services in HWCs has remained almost the same. This will increase the burden on public hospitals and super-speciality clinics and also force the poor to opt for private services, which after a point, aren’t affordable for them.
The rates set for different procedures under Ayushman Bharat are low. This might eventually reduce the quality of services provided or even make them unviable for hospitals. Looking at this scenario, states such as Odisha, Delhi, Telangana, Kerala and Punjab have opted out of the programme.
A programme this large has much room for fraud. India’s poor artificial intelligence or AI-based monitoring has encouraged fraud from families who forge papers of adoption or relationship with the beneficiaries. Here’s how this works: millions of computer service centres (CSCs), government-approved internet kiosks in smaller towns and villages, make the e-cards under Ayushman Bharat.
Under the scheme, though the card is issued to the head of the family, any number of family members may be enrolled to avail benefits under the programme. As such, people who do not meet the eligibility criteria for Ayushman Bharat may either get false poverty certificates to get a card themselves or claim false relationships to people who have these cards.
Finally, Ayushman Bharat does not at this time cover the middle-income section of society. Huge or unexpected medical expenditures can push these families below the poverty line, something India has been fighting since independence.
Data from the Insurance Regulatory and Development Authority of India (IRDAI) show that only 48 crore Indians — that is, less than one in three Indians — have any kind of health insurance. However, the IRDAI and NHA are trying to standardise health insurance policies for this set by ensuring that health conditions (including mental health and age-related problems) are covered by these products.
The private question
Data shows that more than half the services offered under Ayushman Bharat last year were at private hospitals.
Accountability in the private sector continues to be a challenge. Many private hospitals are simply ill-equipped. Ensuring the quality of services under the programme is a massive challenge. Recently, PM-JAY named and shamed 111 hospitals for malpractices. The government also plans to “name and fame” hospitals for good performance.
Unviable rates and delayed payments have also pushed some private players away from participating in the programme.
Ideas for improvement
Like every other public scheme, PM-JAY needs revisions every year to ensure that the programme doesn’t fall behind. For this, Government of India needs to revise the procedural rates to incorporate large hospitals into the programme, fix the infrastructural flaws at the grassroots-level, ensure seamless connectivity in regions such as Kashmir and the North East, improve monitoring at every level to prevent fraud, and finally, include advanced technology to keep a check on fake transactions, beneficiaries, and taking strict legal action against those who fail to comply with the guidelines.
Ayushman Bharat has come up as a strong programme in improving and meeting the Indian population’s healthcare needs, but it has a long way to go. Intersectoral collaborations and political commitment to strengthen the entire healthcare delivery system is the need of the hour for India to achieve the sustainable development goals and emerge as a leader.
This article has been written by Dr Anushikha Dhankhar, who keeps a close eye on public health matters in India via Myupchar.com
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Updated Date: Jan 21, 2020 16:01:43 IST