The Indian state since independence has spent an inconsequential proportion of its resources on public health than just about any other government in the world for the last 70 years. While the Indian state has been highly interventionist in many ways and spheres, there has been a serious lack of provision for public health care in our political culture. We are marked by the health situation today which is absolutely fragmented and dismissive towards our public. The statistics which we have achieved so far: we failed to attain the 2015 millennium development goal of achieving an Infant Mortality Rate of 27 , falling behind at 41 deaths per 1,000 live births. We figure amongst the last of BRICS nations, 60 ranks below Sri Lanka, and worse still, behind war-ravaged countries like Iraq and Libya, and even behind some of the poorest countries in the world such as Cambodia, Timor-Leste, and Myanmar. We are in the bottom quarter worldwide – 143rd among 188 countries – in terms of our overall sustainable development goal (SDG) health index.
The paradox faced by the health sector today, is India has earned the title of “pharmacy of the world” and it has also become a thriving healthcare industry and place for medical tourism. In the midst of this growth and development we have distanced ourselves from the frail and fragile public sector infrastructure which is marred by non-availability of drugs, lack of advanced technology, a severely constrained health workforce and poorly financed public health system. As a result we are crippled by unimpressive performance in healthcare, inability to deliver access and affordable healthcare to our citizens.
The Mission: Ayushman Bharat
India’s healthcare challenges and poor health indicators are widely discussed at various public health forums; but rarely acknowledged in political discourse. For the first time in the history of India there has been an attempt made towards bringing aspects of universal health care under the umbrella of Ayushman Bharat.Under the ambit of Ayushman Bharat- The Pradhan Mantri Jan Aarogya Yojana (PM-JAY) which is the refurbished of National Health Protection Mission has been launched and more than 50,000 beneficiaries have registered. The primary objective of PM-JAY is to reduce the financial burden characterized by high out-of-pocket expenditure, low financial protection, low health insurance coverage among both rural and urban population. The Scheme assures coverage of 10.74 crore poor, deprived and identified categories as per the Socio-Economic Case Census (SECC) data which would cover around 50 crore beneficiaries. The Scheme plans to cover defined 1,350 medical packages in the secondary and tertiary care procedures covering surgery, medical and day care treatments including medicines, diagnostics and transport.
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The other aspect of the health programme includes plans to open 1.5 lakh Health and Wellness Centres that will essentially be upgraded versions of existing health sub-centres, which are the first point of contact in the public healthcare system in India, located in the country’s remotest areas. The programme will be cashless and paperless at public hospitals and empanelled private hospitals. The beneficiaries will not be required to pay any charges for the hospitalization expenses. The benefit also includes pre and post-hospitalization expenses. In a way the government have taken a step towards institutionalising quality and affordable health care without any barriers. It will take a considerable amount of time before we can objectively asses and analyse the programme. However, the hope and confrontations emitting from the programme deserve close scrutiny as it is the most aspirational social health insurance (SHI) programme ever put into practice anywhere in the world. Such an ex-ante probe is not a conjecture as the main aspects of the Scheme are known and there is a wealth of comparative literature on SHI from various countries.
Emerging Challenges
The most daunting challenge as Sudipto Mundle points out is the silence of the financial cost of the programme. He asserts there is “No actuarial database is available to yield a probability distribution of the expected number of different health episodes requiring different treatments at varying costs. Without such a database, insurance agencies cannot estimate the required premium to adequately cover the pooled risk —the ultimate cost of the programme. Depending on the nature of the contract between governments and insurance agencies, the actual cost of the programme could leave a deep hole in the finances of the insurance agencies or the central and state governments.”
A second challenge is where Thomas Isaac has criticised the PM-JAY and it risks having the same fate as the existing Rashtriya Swasthya Bima Yojana, which has been plagued by poor implementation. The Rashtriya Swasthya Bima Yojana, launched in 2008 has a much lower cover at Rs 30,000 per family a year, but has managed to enrol only 3.6 crore of the targeted 25 crore families since its launch. This may lead to coverage erosion and defeat the vision of the PM-JAY programme. The third challenge is the conflict that has been witnessed where the private providers of healthcare have been constantly demanding for high cost treatments not covered under the programme to enhance their profit margins which will ultimately burden the patients.
The fourth area of concern is the makeover approach taken under the PM-JAY. Indeed the promise to fix our primary care delivery system is arguably the foundation of our Public Health Care Delivery System. But under the pretext of converting 1.5 lakh Pubic Health Centers to Health and Wellness Centers will it ease the performance index of our public healthcare delivery system? Finally the sole reliance on the Socio Economic Caste Census, 2011, forms the basis of enrollment for the exercise. Families that were listed as deprived under the census are eligible under the scheme. As a result, in some cases, those who were excluded from the census have also been left out from the PM-JAY, even if they meet other criteria. There has also been teething problems which have emerged pertaining to the verification of beneficiaries.
Today the dynamics of power at work in structuring health outcomes remain largely invisible if analysis focuses on the independent effects on individual, precluding fundamental challenges to the status quo. Today we have a health problem, now what do we do about it, within the existing public health system?’ Have we found the answer yet?
(The author is an advocate practising at Delhi High Court. His views are personal)
