Is Ayushman Bharat the right medicine?

Against the backdrop of inadequate state capacity and a dissolute political class, redeeming the health sector is difficult.

The Bharatiya Janata Party is delighted over Prime Minister Narendra Modi’s ambitious healthcare scheme, Ayushman Bharat, even as five states have refused to join. The government’s intentions may be good, but it takes more than good intentions to do something meaningful.

The government claims that Ayushman Bharat is the world’s largest government- funded healthcare scheme that would benefit 50 crore citizens. It would provide a health coverage of Rs 5 lakh each to about 10 crore financially weak families. Laudable objectives indeed. “The government is pursuing a holistic approach towards the betterment of the health sector. While it focuses on affordable healthcare on one hand, emphasis is also laid on preventive healthcare,” PM Modi said at the launch event. “The number of Ayushman Bharat beneficiaries is almost equal to the population of Canada, Mexico and the United States put together.”

The funding of the scheme is on a 60:40 ratio—60% by the Centre and the rest by states. However, there is no clarity on the quantum of funding. The Union Budget has a provision of just Rs 2,000 crore for the humungous scheme. Ayushman Bharat CEO Indu Bhushan believes that anywhere between Rs 6,000cr and Rs 8,000cr would be needed, whereas V.K. Paul of Niti Aayog has pegged the figure at around Rs 3,500cr.

It would be instructive here to examine the performance of a similar scheme. For the last fiscal, Rs 975cr was allocated for the Rashtriya Swasthya Bima Yojana (RSBY), which has been subsumed under Ayushman Bharat. The allocation was scaled down to Rs 565cr. The release was even less, Rs 450cr, said a parliamentary panel’s report. “Funds as Central share of premium under RSBY of approximately Rs 450 crore were only released for such states that submitted their proposal during the year 2017-18,” said the Parliamentary Standing Committee on Health and Family Welfare in its report in March this year.

It must be mentioned here that the RSBY was a much less ambitious scheme, providing a limited coverage of only Rs 30,000. The parliamentary committee also pointed out low enrolment in the RSBY. “Only 57 per cent of eligible are enrolled and less than 12 per cent of the eligible persons got their hospitalisation covered through RSBY.”

The panel wanted the government to “ensure that inadequacies plaguing the operation and implementation of RSBY are not repeated”. The government has gone several steps ahead; instead of repairing and revamping a modest programme that was poorly implemented, it has come up with a much bigger one. How it will be implemented is unclear.

Evidently, the government and the ruling party are convinced that making big, grand announcements impresses the electorate as doing good work. In this context, good work would have meant painstaking analysis of the shortcomings of the RSBY and the requisite rectification. It would have been a longdrawn-out process involving commitment, diligence, and persistence. Announcing a bigger scheme is much easier; and it’s an event to boot, offering an opportunity to indulge in pomp and pageant.

This brings us to the moot question is: would Ayushman Bharat, touted as a “gamechanger”, succeed? The short answer is: not sure. The reason is simple: the success of any welfare scheme is a function of the efficiency of administration or, what experts call, state capacity; and there has been little enhancement in state capacity since Independence, the lip service paid to administrative reforms by the past and current regimes notwithstanding, Ayushman Bharat may meet with the same fate as other welfarist measures have met with.

For the welfare state, first and foremost, a state, and the Indian state, as it exists today, is rickety and sclerotic. It is incapable of carrying out even the most basic and essential functions: protecting the life, liberty and limb of citizens. There have been reports from several states of synthetic milk and its products—that is, milk made out such hazardous substances as urea and detergent. Adul- teration in edible items is rampant. Likewise with medicines.

Unconscionable activities about the establishments mandated to provide shelter and safety to children have come to the fore. There are a myriad of monitoring mechanisms—the social welfare departments, the Central and state commissions for women and children, the district administration, the local police, local intelligence units, local media, local NGOs, et al. Yet there were Muzaffarpur and Deoria. There was Brajesh Thakur accused of whipping, raping, and pimping young girls, some in preteens. And there are canting politicians who seldom use the term “girl children”; they say “hamaari betiyaan” instead!

Against the backdrop of grossly inadequate state capacity and a dissolute political class, one has to work to believe that Ayushman Bharat would redeem the health sector. A bureaucratised state that fails to carry out its primary duties cannot be expected to do wonders in the social sector. There is no politician in India other than Maratha strongman Sharad Pawar who can gauge the political mood of the country as he alone can. There is no politician who can present a deceptive picture of matters in a clear cut manner as he can. And there is no leader who can play the game of realpolitik on the chessboard with a poker face.

Pawar has been the only one of his kind in national politics, and it is nothing else but his ill luck that he has not been able to achieve his sole ambition in life—that of becoming Prime Minister. From the very beginning, groomed by the late Yashwant Rao Chavan, Pawar has strived to be better than his mentor. Chavan was able to become the Deputy Prime Minister under Chaudhry Charan Singh in the late 1970s, but the coveted position of the head of government has eluded the guileful Maharashtrian leader.

Earlier in the week, he ruffled many a feather in the Opposition parties by claiming that people did not doubt Narendra Modi’s intentions so far as signing the Rafale deal was concerned. It was perceived as his attempt to distance himself from the continuous attack mounted on the Prime Minister by Rahul Gandhi. So much so, that one of his closest aides, Tariq Anwar, the lone NCP Lok Sabha MP from Bihar, severed his links with him and the party, and announced his resignation from Parliament. For Tariq, it was the only option left since he has to battle the BJP in the Hindi heartland with the assistance of known Modi critics, Lalu Prasad Yadav and the Congress.

However, what Pawar stated assumes monumental significance because while vouching for Modi’s intentions in piloting the deal, he indirectly questioned Rahul Gandhi’s own credibility. Simultaneously, he ensured that by praising Modi, something which was acknowledged by BJP president Amit Shah, he linked the Prime Minister as the principal architect of the arrangement with Dassault—the French company selling the Rafale aircraft to India. The other aspect of his double-edged observation was that he magnified the isolation of the Congress on the subject since no leader of any of the Opposition parties had so far publicly backed the agitation against Rafale headed by Rahul Gandhi, though they all have serious reservations on the subject.

Pawar has correctly perceived that the aircraft issue would be a major factor deployed by the Opposition to corner the government, but has chosen to create an impression of supporting Modi, since he does not want Rahul to be the spearhead of the protest, given that in the minds of people there were question marks over his ability to lead the charge. Evidently, he is unprepared to permit the Gandhis to occupy the pole position in Indian politics.

Pawar is widely regarded as a man of all seasons, primarily because of his phenomenal survival instincts at the top level. He has time and again compromised with the circumstances and managed to sustain his position due to his close personal equation with several front-ranking political leaders cutting across party lines. Repeatedly, he has the propensity of conveying his reservations to his oldest ally, the Congress, on a number of important issues so that he continues to have a prominent voice.

Shortly before the 2014 Parliamentary polls, he was able to discern that the Congress was going to lose power and this would impact the prospects of his own party as well. He then decided to take a well-calibrated and conscious decision of contesting for the Rajya Sabha, leaving his traditional Baramati seat for his daughter Supriya Sule for the Lok Sabha. It was more than a coincidence that both Digvijaya Singh, the foremost leader from Madhya Pradesh, and Kumari Selja, the upcoming Dalit face from Haryana, were sent by the Congress to the Rajya Sabha as well. The message was loud and clear that the grand old party, as well as its allies, were mentally prepared that they were going to be trounced in the Parliamentary polls.

Pawar has attained his mega status due to his own perseverance, which over the years has led to a deep understanding of the country’s political situation. In 1978, while he was in his thirties, he was able to outwit a politician of Indira Gandhi’s calibre when he successfully toppled the Congress(S) and Congress(I) coalition government headed by Vasantdada Patil and Nasikrao Tirupude to become the youngest Chief Minister of Maharashtra. Since then, he has never looked back.

In 1991, soon after Rajiv Gandhi was assassinated, he challenged P.V. Narasimha Rao for the Congress leadership, but withdrew from a possible contest after being persuaded by Makhan Lal Fotedar, a close aide of both Indira Gandhi and Rajiv Gandhi.

Pawar was able to sense that his chances of leading the Congress were receding, when in the late 1990s, Sonia Gandhi took over as the party chief. He, along with Tariq Anwar and P.A. Sangma, questioned her legitimacy to hold this position, given her Italian origin. Subsequently, he founded the Nationalist Congress Party (NCP).

At present, he is testing the waters, and wants the leadership issue of a probable alliance against the BJP to be kept open, if the need be, till the post-poll scenario. He is fully aware that there were a number of younger players in the field but is yet hopeful that he still stands a chance. Between us.