While campaigning in Delhi, Home Minister Amit Shah claimed that Chief Minister Arvind Kejriwal has not allowed Ayushman Bharat Yojana to be implemented in the state “for his political interests.” Though political ideology and interests evidently play a role in governance, it is a precarious allegation to put for matters pertaining to health and education. Given that the Aam Aadmi Party’s priority domains are health and education, the claim by the Union home minister requires further scrutiny.
To state that the Delhi government has rejected Ayushman Bharat simply for political interests implies that the scheme is inherently beneficial. A closer look at the modalities of the scheme proves otherwise.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was an extension of a scheme launched by the UPA government. Aware that 70% Indians rely on private healthcare for their health needs, the then Indian government tried out national insurance models such as the Rashtriya Swasthya Bima Yojana (RSBY) in 2008. The aim was to cover hospitalisation expenses up to Rs 30,000 for families below the poverty line.
Its overall performance was poor and the scheme failed to reduce impoverishment. Thereafter, in September 2018, Prime Minister Narendra Modi launched the ambitious AB-PMJAY, the National Health Protection Scheme, in Jharkhand. The scheme subsumed RSBY to provide an insurance cover of Rs 5 lakh to 100 million ‘poor and vulnerable’ families identified by the socio-economic caste Census of 2011. The official website describes this (along with Health and Wellness Centres) as “a flagship scheme of Government of India to achieve the vision of Universal Health Coverage.”
In theory, the scheme increases access and quality by incorporating in the ambit private healthcare providers, thereby increasing the number of facilities and doctors, and by extension reducing time taken to avail treatment and out-of-pocket expenses. However, its absolute disregard for equity and inclusivity is troubling.
AB-PMJAY is available to only those with incomes less than Rs 10,000 per month. This caveat leaves out the majority of the lower-income class and the middle-income group from the safety net of the Central scheme. As of June 2019, India’s per capita income was Rs 10,534. An average Indian will therefore not be covered under the healthcare scheme and will also not be able to afford private healthcare treatments without extreme financial burden. In the particular case of Delhi, the minimum wage in the state exceeds the income criterion of the scheme!
Additionally, anyone who has a scooter, refrigerator, motorcycle and/ or phone is not eligible to avail the benefits of AB-PMJAY, even though they might belong to lower-income strata and would need financial assistance for healthcare matters.
Furthermore, beneficiaries are only entitled to Rs 5 lakh worth of treatment under AB-PMJAY. To even avail Rs 5 lakh, a patient will have to be admitted to a hospital. OPD, medicines and lab tests are not covered under AB-PMJAY.
In a country where the National Pharmaceutical Pricing Authority (NPPA) has hiked the price of the drug-eluting stent (DES) to Rs 30,080, the capping and coverage caveats of AB-PMJAY are far from universalising affordable healthcare to all. The scheme is limited in its reach as well as its provisions.
The inefficiency of the scheme is evident from qualitative interactions with those that have tried to avail the services. A driver originally from Jharkhand and currently residing in Delhi narrated that his wife — eligible for AB-PMJAY — required a hysterectomy.
Upon contacting the AB-PMJAY call centre to get details of hospitals in Gurgaon, he was given details of three private centres for the required treatment. On visiting all three, he was told that none of them performs the surgery and he must try elsewhere. Exasperatedly, he went into the government system and approached Safdarjung Hospital. The cycle of tests and weekly visits started. It has now been three months and the surgery has still not happened.
“My wife and I queue at 3 am at Safdarjung Hospital. By doing that, we get a token number of 2 or 3 by the time the OPD registration opens at 8 am. I then queue to meet the doctor but thankfully because my token number is 2 or 3, it only takes a few hours. Overall, my day ends at 4-5 pm. I do this every Monday because the first time was consultation, the next two-three times were tests, followed by the collection of results and consultation. I have lost my wage for each Monday in the past 11 weeks, but the doctor is good and helpful. There is just too much crowd so they can’t do everything quickly.”
In view of the above, it may be better for our governments to strengthen national healthcare, as opposed to privately routed structures. The Delhi healthcare model is evidence of that.
The World Bank estimates that 90 per cent of all health needs can be met at the primary healthcare level. By building primary health clinics — mohalla clinics — across the capital, the state government took the onus of providing primary consultations and medicines at the doorstep of the people.
AAP government’s Farishte Dilli Ke scheme ensures that, regardless of domicile or income status, anyone can be taken to any hospital (public or private) in case of an accident and the government will pay for the entire treatment.
While they have schemes under the Delhi Arogya Kosh that incorporate private healthcare providers (1,155 surgeries and procedures, as well as 133 diagnostic tests, can be availed cashlessly in private empanelled facilities), they are opening six new government hospitals and have more than doubled their bed capacity by adding infrastructure to existing hospitals with the aim to strengthen state healthcare facilities.
All citizens of Delhi currently have the autonomy to avail free medicines, OPD, lab tests and hospitalisation from the state-run healthcare facilities, with cashless referrals to private providers when required. It is, therefore, necessary to examine AB-PMJAY thoroughly, accounting for the particularities of Delhi’s demography and existing provisions.
Delhi government’s healthcare model has garnered international appreciation for its accessibility and effectiveness from the likes of Kofi Annan and Ban Ki-moon, among other renowned dignitaries. In contrast, the overall India healthcare has a reputation of ranking 145 on the global healthcare access and quality (HAQ) index. To move away from a system that is showing positive results in Delhi, and implement a new system might actually hinder the Delhi government’s objective of providing free and quality healthcare to all the citizens.
Uttar Pradesh and Haryana are neighbouring states to Delhi who have implemented AB-PMJAY. In spite of this, lakhs of patients use the healthcare services in Delhi hospitals, while the vice versa is a rarity. This is a testament to the quality of healthcare provided in Delhi despite not being a part of the AB-PMJAY scheme thus far.
In light of this, it would be acceptable for the Home Minister of India to state that tenets of the AB-PMJAY scheme which are uncovered in the Delhi health scheme to make the model even more robust should be adopted. However, it is absolutely fallacious, misleading and incorrigible for him to say that the scheme is rejected simply for political interest.
The author is a development advisor, specialising in health and education.
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Updated Date: Jan 08, 2020 17:31:16 IST