How Equitable Will Ayushman Bharat Be?

The National Health Protection Scheme, better known as Ayushman Bharat (collectively referred  to as AB–NHPS), was launched in September 2018. As the largest publicly funded health insurance scheme in the world, it intends to offer financial risk protection to the poorest and the vulnerable. It aims to cover approximately 40% of India’s population spread across its rural and urban areas (GoI 2018). Each identified household has to be insured for an annual sum of Rs 5 lakhs for a variety of ailments needing secondary and tertiary healthcare (GoI 2018). The transactions will be cashless in the empanelled public and private hospitals. A decade ago, in 2008, the Rashtriya Swasthya Bima Yojana (RSBY) was launched to safeguard the poor against the catastrophic consequences of high out-of-pocket (OOP) expenses on health. As a precursor to the AB–NHPS, the RSBY was far more modest in its scope, offering a cover of Rs 30,000 per annum to enrolled households. As on 31 March 2017, there were 3.6 crores active smart cards under the RSBY, with the total number of hospitalisation cases being more than 1.4 crore (MoHFW n d).

Both the AB–NHPS and RSBY are measures intended to promote equity through financial risk protection. High OOP expenditure characterises spending on health in India. In rural India, 67.8% households report income or savings as a major source of finance for meeting expenses related to hospitalisation. The figure is higher in urban India, with 74.9% of the households majorly relying on income or savings for such expenses (NSSO 2016). This can have an impoverishing effect, pushing households into poverty. Overcoming financial hurdles increases access to healthcare. But, the potential of health insurance schemes such as the AB–NHPS and the RSBY to promote equity goes beyond easing financial hardships alone. They can improve access to healthcare by reducing inequities at the household and societal levels. 

Equity in Health

Physical accessibility, financial affordability, and acceptability are the three dimensions of access to healthcare (Evans et al 2013). Universal access to healthcare presupposes equity, where people belonging to different social groups may access care without facing socio-economic disadvantages. It brings us closer to the goal of universal health coverage. In recent decades, equity has been an enduring concept in public health policy and practice. Equity in health is defined as

“the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage—that is, wealth, power, or prestige.”

It is an ethical concept based on the principle of distributive justice (Braveman and Gruskin 2003). Inequity across social groups manifests in many ways. Margaret Whitehead observes that members of disadvantaged social groups have poorer survival chances and die at younger ages. Their “experience of illness” is different, and is marked by an earlier onset of chronic disease and disability. There are other dimensions of health and well-being showing a similar pattern of “blighted quality of life” (Whitehead 1991: 218). 

Hospitalisation is a test case for equity. Hospitalisation episodes are generally costlier than outpatient (ambulatory) care. They are more time-consuming too. Inpatient admission in hospitals can mean loss of wages for patients and their caregivers. Caregiving responsibilities in the household are affected if a female member is hospitalised. Hospitals that are located in distant or inconvenient to access areas can adversely affect utilisation. In effect, hospitalisation can perpetuate inequities at the household and societal levels since it requires time, money, and human resources.  

This article elaborates on three aspects of equity that determine access to healthcare in general, and hospitalisation in particular. The dimensions are: differential access of members within a household; differential access of social groups in a given population; and geographical differentials in provisioning of healthcare services. Relevant literature is cited to show how such differentials may manifest in utilisation of healthcare services. Empirical evidence is also drawn from a recent population-based study showing how health insurance scheme for the poor may advance equity, or conversely, perpetuate inequity. The study is located in villages of predominantly rural blocks in five backward districts of West Bengal. The districts are: Murshidabad, Malda, Dakshin Dinajpur, Uttar Dinajpur and (undivided) Jalpaiguri. At the time of the study, the RSBY scheme had been operational for two to three years in each sampled block. Households listed as being below poverty line (BPL) were eligible to be included in the study. Information was collected from 449 households through quantitative face-to-face interviews. A total of 1,947 persons resided in these households, thus resulting in an average household size of 4.3 members. Secondary data from various government sources has also been analysed.^[1]

Household as a Site of Inequity

The household is a site of unequal distribution of power and resources. It is also a site where various types of discrimination are played out. There is differential access to healthcare for members of a household. Marginal members in a household may be discriminated against, especially in a costly event such as hospitalisation. It has been seen that the overall hospitalisation rate is the lowest for the poorest households. Further, the rate of hospitalisation of females in these households is relatively higher than the males. This could be explained by the fact that the prevalence of morbidities (both acute and chronic ailments) is higher for females (NSSO Report no 441 cited in Mishra 2006:10) It is in cases of “extreme and incapacitating ill health” that women in the poorest households get hospitalised (Mishra 2006: 30). However, services accessed for females “are usually the ones that are convenient and cheap,” and the facilities accessed are those that are “cheaper and/or closer to the place of residence” (Mishra 2006: 31). The average expenditure per hospitalisation is lower for females in both urban and rural India, and in public and private hospitals (NSSO 2016: 45). Education levels also influence healthcare seeking (Singh and Kalaskar 2017). The differently abled face systematic discrimination and exclusion that hampers their access to healthcare.  

Our study showed that the access to healthcare is likely to improve for conventionally disadvantaged members in those households that have active RSBY cards (Table 1). The hospitalisation rates improve for persons with disability in the households with active RSBY cards. In such households, 20% of the differently abled were hospitalised in the past one year prior to the study. No person with a disability was hospitalised in the households without the card/ lapsed card during the same period. Individuals with low levels of schooling (primary schooling or less) are more likely to get hospitalised in those households that have active RSBY cards. The hospitalisation rate for females is higher than that for males in both types of households, a finding that is consistent with national patterns in the poorest households. The percentage of females getting hospitalised is slightly lower in the households with active RSBY cards. This merits further exploration.

Disadvantaged Social Identities 

For the Scheduled Castes (SCs), the hospitalisation rate is lower than the national average. The Scheduled Tribes (STs) are least likely to be hospitalised (NSSO 2016: A-104). The hospitalisation rate for Muslims is lower than that for Hindus and Christians (NSSO 2016: A-104). The possession of an active RSBY card in the study site is likely to mitigate such sociocultural disadvantages. In households with active RSBY cards, we found hospitalisation rates to be similar (varying within a narrow range of three percentage points) for Hindus, Muslims and Christians. From among households without RSBY cards or lapsed cards, Muslims were most likely to be hospitalised. This is primarily because the Muslim-dominated districts of Murshidabad and Malda also had the highest number of empanelled hospitals. Households with active RSBY cards witnessed similar hospitalisation rates for the general castes, the SCs and the STs. In contrast, members of the general caste households without RSBY cards or with lapsed cards were most likely to be hospitalised. Members of the STs were least likely to be hospitalised in such households. There was a difference of more than 20% between the hospitalisation rates of the general castes and ST groups in the households without the RSBY cards/ lapsed cards (Figure 1).

Uneven, Inadequate and Urban-biased Distribution

Unless there are compelling reasons, people prefer a nearby healthcare facility for seeking care. Our study showed that 53.1% of the households preferred the nearest hospital for hospitalisation. Preference for a RSBY-empanelled hospital was low, with only 15.9% of the households preferring such a facility. We found that the distribution of the RSBY-empanelled hospitals was uneven across the five study districts. A total of 103 healthcare facilities were empanelled in the five districts under the RSBY scheme. This included a small number of inactive hospitals. Murshidabad accounted for the highest number of empanelled hospitals (50) and Dakshin Dinajpur had the lowest number of such hospitals (7). Empanelled hospitals were overwhelmingly located in urban areas of the districts. In fact, neither Uttar Dinajpur nor Dakshin Dinajpur had even one empanelled hospital located in their rural areas. Jalpaiguri had only one empanelled hospital located in the rural areas, while there were 15 such facilities in the urban areas. 

People belonging to BPL households constitute the prime beneficiaries of the RSBY-scheme. Yet, for the five study districts taken as a whole, there was one RSBY-empanelled hospital for BPL population of over a lakh. There were wide inter-district variations in this aspect as well. Murshidabad had one RSBY-empanelled hospital per 80,253 BPL individuals. For the districts of Malda and Jalpaiguri, there was one RSBY-empanelled hospital for more than 1.5 lakh BPL individuals. 

Implications for National Health Protection Scheme

The RSBY scheme has been subsumed under the AB–NHPS. Some of the weaknesses of the RSBY scheme will be plugged in order to prevent misuse and detect malpractices. For instance, caesarean sections and hysterectomies are not allowed in private hospitals under the AB–NHPS (Jha 2018). Malpractices such as admitting more patients than the bed strength in the hospital can be detected and flagged by the system software (Jha 2018). There is no limit on the number of household members who can be enrolled under the scheme (GoI 2018). Such corrections will undoubtedly help to advance the goal of universal health coverage in an ethical and equitable manner. 

The design of the RSBY scheme also offers lessons in what may be done to avoid perpetuating inequities. Health insurance schemes can counter both intra- household and inter-household inequities. As discussed in the previous sections, possession of an active RSBY card has promoted equity within the household and across social groups. However, the uneven distribution of India’s health infrastructure and the inherent urban bias could not be overcome. 

In both schemes, empanelled public and private hospitals provide services. Only public hospitals will provide services during the first phase of AB–NHPS (Jha 2018). Subsequently, the AB–NHPS will allow private facilities to be empanelled for provision of services. There has been growth in the number of public hospitals in India with 3,276 public hospitals being added in three years. As per recent reports, the number of public hospitals in India stands at 23,582. Of these, 84% are in rural India. The average population served per bed in a public hospital is 1,844 (CBHI 2018: 260). The number of hospital beds per 10,000 persons in India is nine as against the global average of 30 (WHO SEARO 2018). Hospitals in India are disproportionately located in cities and towns. The National Commission on Macroeconomics and Health observes in its report that the private sector in India “consists largely of sole practitioners or small nursing homes having 1-20 beds, serving an urban and semi-urban clientele and focused on curative care.” Based on a study of eight middle-ranking districts across states in the country, the report notes that there is “a highly skewed distribution of resources,” with 88% of the towns having a facility compared to 24% rural settlements. The private sector accounts for 49% of the beds in these eight study sites (MoHFW 2005: 5). 

The provisioning of services by the private sector under the AB–NHPS has been left to market forces. In an interview, the chief executive officer of the AB–NHPS expressed hope that "once the scheme is running full scale, we believe many new private hospitals will come up to cater to the needs of the patients even in rural parts of the country, because they will now be covered under the insurance scheme; government will pay for their treatment” (Jha 2018). Going by the current spatial distribution of the private health sector in India, its growth in response to the AB–NHPS is likely to be patchy and concentrated in geographical pockets. The current rural–urban inequity in India will continue into the future, at least in the short term. The unevenness and urban bias in India’s health infrastructure restrict all three dimensions of access to healthcare, limiting as they do physical accessibility, financial affordability and acceptability of health services. While health insurance schemes such as the RSBY may have countered some of the inequities operational within and across the households, they falter in the face of geographical inequities. The pattern is likely to be repeated under the AB–NHPS. With such a compromise on equity, the goal of universal health coverage is unlikely to be reached in the near future.