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Ayushman Bharat

Hurdles to Implementation One Year On

Shah Alam Khan (shahalamkhan70@gmail.com) teaches at the Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi.

 

Taking into consideration the model of the Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana, some valid questions regarding the operationality and feasibility of the scheme are examined. The shortcomings of the scheme are brought forth and a solution is offered so that the scheme does not stand in contradiction to various health schemes of the past.

 

The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB–PMJAY) was launched by the Government of India in 2018 (National Health Authority nd). The AB–PMJAY defines a benefit cover of ₹5 lakh per family per year for secondary and tertiary care hospitalisation and it is aimed at covering a total of 10 crore families (approximately 50 crore persons or 40% of the country’s population based on the socio-economic and caste census database) (Bakshi et al 2018). The premise of the scheme is to achieve universal health coverage (UHC) and to move towards achieving the sustainable development goals (SDGs) to which India is a signatory. As more and more data becomes available for this ambitious scheme, it becomes necessary to evaluate as to whether the track chosen by the state for achieving UHC has reached anywhere near the assumed end point. In the first few months of its inception, questions were raised on the operationality and the feasibility of the AB–PMJAY (Bakshi et al 2018). It is, thus, important to examine whether these valid questions have been answered or whether the government has moved ahead with the scheme without due consideration of issues of operationality and feasibility.

Insurance-based Model

The insurance-based model of the AB–PMJAY and the economics involved has been questioned by many (Patnaik 2018). The operational feasibility of the AB–PMJAY was also questioned both by health economists and health activists. It was felt at the time of its inception that the scheme was susceptible to issues pertaining to hospital empanelment, patient enrolment, and the possibility of corrupt practices.

Past experience with insurance-based models of healthcare in this country has not been good. The schemes were found to be inequitable, inefficient, and did not provide financial protection. The population covered under the AB–PMJAY overlaps with, but is not the exact mirror image of, the population under another insurance-based scheme of the previous government called the Rashtriya Swasthya Bima Yojana (RSBY). The RSBY was targeted at below poverty line (BPL) families. An article in the Lancet in 2016 revealed that around 80% of the reimbursements under the RSBY went to private health set-ups. Besides, the out-of-pocket expenditure for people seeking healthcare was among the highest in India (Mackintosh et al 2016).

In line with the expected problems of operationality of the AB–PMJAY, the RSBY too had its share of issues. In a study conducted in West Bengal, Bandyopadhyay and Sen (2017) found that the district-wise performance of the RSBY was extremely variable, particularly in terms of enrolment of BPL families in the scheme. They assign multiple reasons to the same and, interestingly, these very factors would be at work in the enrolment of families even for the AB–PMJAY. They concluded that a combination of private hospital providers working together with a private insurance model created a monopoly that is failing to control costs and monitor for quality or health outcomes. Thus, on the one hand, premiums are increasing rapidly, whilst, on the other, providers (due to lack of regulation and oversight) are able to act in a monopolistic and unethical manner (Bandyopadhyay and Sen 2017). The social factors which, thus, govern the functioning of a scheme like the RSBY would definitely have a bearing on the operationality of the AB–PMJAY.

Hindrances in Functioning

In a paper analysing the enrolment of private hospitals in the health insurance network in India and its implications on the AB–PMJAY, Choudhury and Datta (2019) concluded from an extensive analysis that the empanelment of private hospitals by insurance companies in India is relatively low in states with low per capita incomes, where a substantial proportion of eligible beneficiaries under the AB–PMJAY are concentrated. This appears to be a serious flaw which has by and large remained unanswered by the policymakers and needs to be evaluated in detail towards achieving the benefits of the AB–PMJAY.

Corruption is the other problem with the operation and functioning of the AB–PMJAY. Instances of corruption within the AB–PMJAY have already been noticed. The Union Ministry of Health and Family Welfare website gives a breakdown of some of the statistics, which plague the AB–PMJAY on the completion of its first year. According to this information, there are confirmed frauds in 1,200 hospitals involving the AB–PMJAY. Of these, investigations have been completed in 376 hospitals and first information reports (FIRs) filed against six hospitals. After the conclusion of investigations, a penalty of ₹1.5 crore has been levied and 97 hospitals have been delisted from the scheme. Within the private sector, 71% of the hospitals empanelled have less than 25 beds and offer non-specialised care (Mani 2019). The document,Lessons Learned in one year implementation of PM–JAY,” available on the AB–PMJAY website, enlists fraud as a challenge that needs to be tackled for better implementation (National Health Authority 2019). Thus, the potential problems of “profit-motivated” supplier-induced demand by private healthcare providers and corrupt practices are possible ethical burdens of the scheme (Gopichandran 2019).

The other problem of implementation of the AB–PMJAY which has been highlighted recently in the national media is its inability to serve the poorest of the poor who would previously benefit under other government schemes, like the Rashtriya Arogya Nidhi (RAN). A recent report published in the Indian Express revealed that seriously ill patients—for example, those suffering from illnesses like end-stage kidney disease, chronic liver disease, and blood cancers—are being denied treatment under the AB–PMJAY, since these illnesses are not among the 1,350 medical packages defined under the scheme and, hence, are not covered by it. These patients, it is reported, are also deprived of the benefits under the RAN scheme since they are now AB–PMJAY cardholders (Saxena 2019). It has been noted that the AB–PMJAY scheme provides coverage of medicines post discharge up to 15 days only. A large number of patients, particularly cancer patients, require long-term medication on an outpatient basis. In the past, such patients could get medicines (on an outpatient basis) through the RAN scheme. The need for admission as a criterion to avail benefits under the AB–PMJAY is a big blow to this cohort of patients. This has not only restricted the reach of the benefits to the poorest of the poor, but has also worked against the principles of the RAN umbrella scheme, which is to give financial benefit to the poor in the treatment of cancer.

In fact, the AB–PMJAY and RAN should have complemented each other to provide an ideal situation of targeting the poorest and the deprived of the country. Instead, the very approach of excluding patients enrolled in the AB–PMJAY from availing the benefits within the RAN umbrella scheme, along with the exclusion of diseases they suffer from under the AB–PMJAY, has created a dangerous situation for millions of prospective RAN beneficiaries. This dangerous and dismal situation will subsequently lead to an increase in out-of-pocket expenditure, adding to disease-induced impoverishment.

The cost of consultations in the outpatient department, along with the cost of medicines and diagnostics is the major contributor to out-of-pocket expenditure in India, which is not covered in the AB–PMJAY. This leads to major hardships for large numbers of patients. In a country like India, social and geographical factors compel a significant number of people (even with serious ailments) to opt for outpatient as compared to inpatient treatment. The lack of coverage of outpatient costs in the AB–PMJAY is a careless oversight on the part of the policymakers who designed the scheme.

Social Inequities in Accessibility

In India, the neo-liberal policies of the 1990s led to major social inequities. This, in turn, led to inequalities in seeking healthcare. The poor and the underprivileged were left at a disadvantage with regard to both, the accessibility and affordability of healthcare. Invariably, health is not a product only of efficient medical services, but is mainly determined by the social and economic conditions of the people, including their ability to earn, eat, afford decent living conditions, and access healthcare when in need (Bajpai and Saraya 2018). The insurance-based model of healthcare delivery, like the current AB–PMJAY, is the distillate of that process of social inequality. If the real commitment is to UHC, then unfortunately only an insurance-based healthcare delivery model is not the answer. We need to learn from countries like Thailand. Thailand has achieved UHC in public health at an expenditure that is feasible for the Indian scenario too (Sundararaman 2018).

In conclusion, a scheme like the AB–PMJAY is not without its intrinsic flaws and shortcomings. In the last one year, these shortcomings have been visible at multiple levels. Hence, the operational feasibility of this scheme needs monitoring at multiple levels. Marking a finite end point of the scheme is not possible. Clashes and contradictions with other schemes that have historical importance with regard to the social security net in India (like the RAN) are deleterious to the intent of an Ayushman Bharat. A simpler solution to the problem would be to incorporate the scheme into the UHC framework, which of course needs stronger legs to stand in our country.

References

Bajpai, V and A Saraya (2018): Health beyond Medicine: Some Reflections on the Politics and Sociology of Health in India, Delhi: Aakar Books.

Bakshi, H, R Sharma and P Kumar (2018): “Ayushman Bharat Initiative (2018): What We Stand to Gain or Lose!,” Indian Journal of Community Medicine, Vol 43, No 2, pp 63–66.

Bandyopadhyay, S and K Sen (2017): “Challenges of Rashtryia Swasthya Bima Yojana (RSBY) in West Bengal, India: An Exploratory Study,”
International Journal of Health Planning and Management, Vol 33, No 2, pp 294–308.

Choudhury, M and P Datta (2019): “Private Hospitals in Health Insurance Network in India: A Reflection for Implementation of Ayushman Bharat,” NIPFP Working Paper Series, Paper No 254, National Institute of Public Financing and Policy, New Delhi.

Gopichandran, V (2019): “Ayushman Bharat National Health Protection Scheme: An Ethical Analysis,” Asian Bioethics Review, Vol 11, No 1, pp 69–80.

Mackintosh, M, A Channon, A Karan, S Selvaraj, E Cavagnero and H Zhao (2016): “What Is the Private Sector? Understanding Private Provision in the Systems of Low-income and Middle-income Countries,” Lancet, Vol 388, No 10044, pp 596–605.

Mani, V (2019): “Patients to Fake Websites: One Year of Ayushman Bharat Reviewed in Numbers,” Business Standard, 18 September, viewed on 7 November 2019, https://www.business-standard.com/article/current-affairs/patients-to-fake-websites-one-year-of-ayushman-bharat-reviewed-in-numbers-119091701619_1.html.

National Health Authority (nd): “About Pradhan Mantri Jan Arogya Yojana (PM–JAY),” Government of India, New Delhi, viewed on 2 November 2019, https://www.pmjay.gov.in/about-pmjay.

— (2019): “Lessons Learned in One Year Implementation of PM-JAY 2018–19,” Government of India, New Delhi, viewed on 7 November 2019, https://pmjay.gov.in/sites/default/files/201909/Lessons%20Learnt%20small....

Patnaik, Prabhat (2018): “Ayushman Bharat,” Ideas, 1 October, viewed on 4 November 2019, https://www.networkideas.org/featured-articles/2018/10/ayushman-bharat/.

Saxena, A (2019): “Patient with Serious Illness Falling through Gap between Two Schemes: AIIMS,” Indian Express, 22 September, viewed on 7 November 2019, https://indianexpress.com/article/india/patients-with-serious-illnesses-falling-through-gap-between-two-schemes-aiims-6017236/.

Sundararaman, T (2018): “How Thailand Built a Universal Healthcare System without Giving Private Sector Free Rein,” Scroll, 20 February, viewed on 4 November 2019, https://scroll.in/pulse/869171/thailand-built-a-universal-healthcaresyst....

Updated On : 29th Nov, 2019

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