WHAT AILS AYUSHMAN BHARAT?
On Sunday, September 23, Prime Minister Narendra Modi launched the Pradhan Mantri Jan Arogya Yojana (PMJAY) insurance scheme aka ‘Modicare’. It was billed, with his characteristic grandiloquence, as the ‘world’s largest healthcare programme’, a reform that will be ‘visible from space’. Fact is the government’s National (Rural) Health Mission, launched in 2013, covers a much larger population than the 107 million families or 500 million supposed beneficiaries of the PMJAY.
For more than a decade, schemes like the Rashtriya Swasthya Bima Yojana at the national level, and state schemes in Andhra Pradesh, Tamil Nadu, Maharashtra, Rajasthan and Karnataka, have been implemented with annual covers ranging from Rs 30,000 to Rs 3 lakh per family. The PMJAY is designed on similar lines.
It is necessary to look at the evidence from these schemes, which the government seems to have ignored.
These schemes are meant to protect people from incurring large expenses on hospitalisation. Studies of previous schemes show that patients have to pay from their pockets even though hospitals are supposed to provide free services. According to the 71st round National Sample Survey, an insured patient going to a private hospital still ended up paying an average of Rs 18,000 from her pocket. Private hospitals have been found providing unnecessary and selective profitable services.
So, while their benefits are uncertain, what are the costs of these schemes? The experience of states like Kerala, Rajasthan and Chhattisgarh is that claims keep rising under these schemes, premiums shoot up and the government ends up paying. In Chhattisgarh, for instance, the premium has increased from about Rs 300 to Rs 1,100 in six years. The state will need to spend Rs 600 crore this year on insurance for a cover of just Rs 50,000.
Claims money, it has been found, goes mainly to private hospitals: scheme data shows private hospitals
receiving 80 per cent of claims money in Chhattisgarh, over 70 per cent in Andhra Pradesh and Maharashtra and more than 60 per cent in Tamil Nadu. These hospitals also charge patients on the sly. And in this scheme of things, both the public and the government lose while private hospitals profit.
The PMJAY will damage public healthcare delivery. Not only will less money be now available to build/improve government hospitals, government doctors will continue to refer their patients to private hospitals for a ‘cut’.
India should learn from developing countries who have achieved universal healthcare. Thailand is such an example. The Thai healthcare system is adapted from the UK model but tweaked to suit their context. It is built on a strong public health system for primary and secondary healthcare. More than 75 per cent of hospitalisation is in government facilities. Private hospitals are used judiciously for high-end tertiary care. Instead of insurance, they have innovative public financing, which is responsive to the needs of different populations and areas. The Thai government spends 3 per cent of its GDP on health; India, by comparison, spends just over 1 per cent.
The upgradation of 150,000 Health SubCentres and PHCs as ‘Health and Wellness Centres’ (HWCs) under Ayushman Bharat is an opportunity for better primary healthcare. But it needs more than the measly Rs 1,200 crore budgeted within the limited National Health Mission funds. It needs closer to Rs 2.5 lakh crore at Rs 17 lakh per HWC. The Community Health Centres and District Hospitals can be strengthened too. Our approach to human resources for health needs to change: more local youth need to be trained as healthcare providers to serve in their districts. A few private hospitals could be empanelled for limited high-end services through referrals from district hospitals.
The PMJAY mimics the US health system, which is expensive with poor outcomes; the Thai model would have served India better. Far from being the panacea for India’s healthcare ills, the PMJAY is likely to exacerbate them and be an even bigger disaster than the previous health insurance schemes.
The PMJAY will damage public healthcare delivery. It mimics the US health system, which is costly with poor outcomes
Sulakshana Nandi is a public health researcher and National Co-convenor of the Jan Swasthya Abhiyan (People’s Health Movement India)