What is the Ayushman Bharat Scheme?
The Ayushman Bharat Scheme, launched by the Centre in September 2018. The government health insurance scheme covers most medical treatment costs and offers cashless hospitalization services through the Ayushman Bharat Yojana e-card. Touted as one of the world’s largest health insurance schemes, approximately 50 crore beneficiaries are eligible for the scheme.
It comprises of two schemes:
- National Health Protection Scheme:
This aims to provide assurance cover to 10 crore families up to Rs 5 Lakh crore cover per year.
- Health and Wellness Centre: It aims to overhaul 1.5 lakh primary health centers in India.
- The scheme will be completely paperless, cashless, and portable.
Challenges Faced by Indian Health Sector:
- Low Public Health Expenditure as % of GDP:
- According to National Health Profile, 2018 government spends only 1.3% of its GDP on public healthcare, it remains way below the global average of 6 percent.
- It results not only in poor healthcare infrastructure in rural India but also in severe scarcity of doctors, and low health insurance penetration.
Status of Health Sector in India
- Total industry size: Around $160 billion in 2018 and expected to cross $372 billion by 2022.
- Employment Generation: Expected to generate 40 million jobs in India by 2030. 1 lac jobs are expected to be created from Ayushman Bharat,
- Primary Health Centres (PHCs): As of September 14, 2018, the number of PHCs increased to 32,899, and several sub-centers reached 167,809.
- The private sector accounts for 74 percent of the country’s total healthcare expenditure, whereas the Public sector: 28% in rural areas; 21% in urban.
Continuously Improving Health Indicators:
- Life Expectancy: Average lifespan went up from 48 in 1980 to 67.9 in 2014.
- MMR: From an MMR of 556 in 1990, the nation has achieved an MMR of 130 by 2014-16.
- IMR: The infant mortality rate at the national level stands at its lowest i.e. 34 per 1,000 live births in 2018.
- Institutional Delivery: As per NFHS-4, nearly 79% of women are now giving birth in public and private hospitals.
- Immunization: Around 75% of children below 12 months of age were fully immunized by 2016 end.
- Intensified Mission Indradhanush (IMI) Program aims to achieve 90% immunization coverage by Dec 2018.
- DALY rate: The per person disease burden, measured as disability-adjusted life year (DALY) rate, dropped by 36% from 1990 to 2016.
Various Stats that Still Pose Significant Challenge:
- Out-of-pocket (OOP) Medical Expenses: 62% of all healthcare costs in India, whereas it is 11% in the U.S., 32% in China, and the world average remains around 18.2%.
- Insurance Coverage: 27% Indians as per National Health Profile 2018.
- Total expenditure: India’s total expenditure, public and private, is around 4.7% of GDP, much below the world average of around 10%.
- Rural-Urban Divide: 75% of all doctors are in urban areas, accounting for only 31% of India’s population.
- Poor Doctor-Patient Ratio: One allopathic government doctor in India, on average, attends to a population of 11,082, whereas WHO recommends a ratio of 1:1,000.
Lack of Health Infrastructure:
- Rural-Urban Divide: Concentration of doctors, secondary and tertiary facilities in Urban areas weakens the cause of Universal Health Coverage
- Doctor-Patient Ratio: It remains abysmally low, about one-tenth of what is recommended by WHO.
- Primary Health Centres (PHCs): PHCs remain very scarce in number in catering to the needs of 1.3 billion strong Indian populations.
- Secondary and Tertiary Sector facilities are mainly located in urban areas.
Inadequate Implementation of NHP:
- Poor Monitoring and Implementation: Accountability failures along with the absence of mechanisms to ensure foolproof implementation of schemes free from quacks, intermediaries, etc.
- It also happened due to a lack of empathy and a sense of responsibility among healthcare professionals.
Weak Regulatory Mechanism:
- Recently, the Medical Council of India (MCI) was dissolved as the institution was marred by corrupt practices such as non-transparent and biased inspection for medical college approval leading to poor quality standards in Indian Medical colleges.
- Earlier the Supreme Court-appointed an oversight committee to supervise the functioning of MCI. This committee abruptly resigned stating the MCI was non-compliant and non-cooperative with the committee.
- The National Medical Commission Bill, which would have replaced the Indian Medical Council Act, 1956, is also pending in the parliament.
Healthcare in Tribal Areas:
- Tribal and backward regions remain at the bottom ladder of India’s Human Development Index (HDI) health indicator.
- Interregional disparity, unspent budgetary allocation, negligence of duty by officials and low level of people literacy place them at the lowest rung of the ladder.
Poor Health Insurance Penetration:
- Only 27% of Indians have been given insurance cover even after flagship RSBY.
- Earlier, Rashtriya Swasthya Bima Yojana (2007) failed to achieve its desired objective of meeting the health insurance needs of the poor due to the following reasons:
- High transaction costs due to insurance intermediaries,
- Low coverage for primary health resulting in high out-of-pocket expenditure.
- Non-targeted approach: Not designed as per state-specific disease profile resulting in lack of outcome-oriented approach.
Way Ahead:
- World Economic Forum estimated that India stands to lose $4.58 trillion before 2030 due to NCDs and mental health conditions. Hence, timely actions are needed.
- Behavioral Change: On the lines of “Hum Fit Toh India Fit” by promoting healthy dietary practices, physical activity, prevention of smoking, alcohol, and pollution.
- Improved Health Infrastructure: Increase public health expenditure, Better monitoring of schemes and targeting of patients, etc.
AYUSHMAN BHARAT SCHEME DURING COVID 19
With the raging coronavirus outbreak in India come mounting hospital bills.
This is considerably difficult in a country where only 20% of the population has health insurance coverage. Consequently, Indians pay the most out of their pockets globally for accessing healthcare services.
India has operationalized 75,532 Ayushman Bharat-Health and Wellness Centres so far despite the COVID-19 pandemic and is on track to functionalize 1.5 lakh HWCs by December 2022.
India has always had free public healthcare – on paper. Insurance is the second-best solution. However, in the medium run, given that the government’s capacity to create infrastructure is limited, leveraging a vast private sector is inevitable. Let us also note that a majority of Indian states have opted for the Trust route and not the insurance route for PMJAY.
The poor in India have been waiting for publicly provided and financed universal health care for decades. If we depend on the public sector alone, that wait will continue for decades. India’s private healthcare sector has been growing through implicit subsidies from the government and the sheer absence of “public” itself in the sector. Naturally, they must give back— at reasonable rates— to society, through accountable systems. Perfect need not be the enemy of the good, and in India’s case, the resulting wait will have horrible human costs. Remember, rural health infrastructure is being expanded at an unprecedented pace in parallel. It is undoubtedly not either-or, and we need to avoid falling into that trap
Express empanelment of hospitals was initiated as a response to a need during the lockdown, to ensure that a sufficient level of non-COVID-19 critical health services capacity remains online. It was an emergency measure of the government, and reportedly it has worked. From 15223 in April 2020, the number of impaneled hospitals has grown to 24666 in December 2020, 46% of these in the private sector.
SHORTCOMINGS IN THE AYUSHMAN BHARAT SCHEME
There have been media reports of misuse of the Ayushman Bharat scheme by unscrupulous private hospitals through the submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facilities.
There have been media reports of misuse of the Ayushman Bharat scheme by unscrupulous private hospitals through the submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facilities.
Under the scheme, though the card is issued to the head of the family, any number of family members may be enrolled to avail of benefits under the program. As such, people who do not meet the eligibility criteria for Ayushman Bharat may either get false poverty certificates to get a card themselves or claim false relationships to people who have these cards.
A program this large has much room for fraud. India’s poor artificial intelligence or AI-based monitoring has encouraged fraud from families who forge papers of adoption or relationship with the beneficiaries. Here’s how this works: millions of computer service centers (CSCs), government-approved internet kiosks in smaller towns and villages, make the e-cards under Ayushman Bharat.
CONCLUSION
Like every other public scheme, PM-JAY needs revisions every year to ensure that the program doesn’t fall behind. For this, the Government of India needs to revise the procedural rates to incorporate large hospitals into the program, fix the infrastructural flaws at the grassroots level, ensure seamless connectivity in regions such as Kashmir and the North East, improve monitoring at every level to prevent fraud, and finally, include advanced technology to keep a check on fake transactions, beneficiaries, and taking strict legal action against those who fail to comply with the guidelines.
