We highlight some of the challenges that Ayushman Bharat faces and explore the possibility of developing a truly universal health insurance programme in the near future, along the lines of the one in Thailand.
The Ayushman Bharat–Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) was launched by Prime Minister Narendra Modi on 23 September. It has been billed as the largest government-funded healthcare programme and is expected to cover approximately 50 crore beneficiaries. Beneficiary families under the scheme, estimated to be around 10 crore, would get an insurance cover of Rs 500,000 per year.
The scheme is touted as a game-changer because an overwhelming section of Indian households have no access to healthcare insurance or assurance. According to the findings of the seventy-first round of the National Sample Survey Office (NSSO), 85.9 per cent of rural and 82 per cent of urban households had no access to healthcare insurance. Further, information on healthcare expenditure in India, while pegging the overall rate of expenditure at 3.9 per cent of the gross domestic product (GDP), estimates that only 1.1 per cent of this expenditure is government-financed. It has therefore been estimated that 70 per cent of healthcare expenditure in the country is privately financed and 62 per cent is in the form of out-of-pocket expenses, which are considerably higher than the World Health Organization-mandated 40 per cent ceiling for such expenditure.
The high levels of private financing of healthcare coupled with an excessive reliance on private sector facilities in the absence of quality public health services pushes millions of Indians into straitened financial conditions. Research based on NSSO data has shown that an estimated 7 per cent of all the households falling below the poverty line was on account of out-of-pocket expenses. It is in this backdrop that the AB-PMJAY, also dubbed as “Modicare” in some quarters, could be particularly revolutionary, as it allows 50 crore economically backward Indians access to healthcare free of cost.
An estimated 1,354 packages have been included by the Health Ministry under this insurance scheme, which will include treatment for coronary bypass, knee replacement, and stenting, among others. Beneficiaries can use facilities at government or empanelled private hospitals, thus affording them a choice. Critically, the insurance scheme is only one prong of the overall Ayushman Bharat framework, with the other one being the setting up of a network of 150,000 health and wellness centres (HWC), which would provide free universal and primary healthcare. This is also a potentially game-changing development since so far the lowest rung of the healthcare system has focused on antenatal and postnatal care along with immunisation services. With the planned provision of universal healthcare at the primary level, it is expected that some of the load borne by the secondary and tertiary care systems would ease up.
This healthcare initiative of the Modi government has drawn praise from various quarters, including from the editor of the prestigious medical journal Lancet. He lauded the focus on health as not only “a natural right for India’s citizens, but also as a political instrument to meet the growing expectations of India’s emerging middle class”. However, concerns have been expressed in some quarters over the financial cost that this scheme would entail, with apprehensions being expressed over the lack of sufficient data vis-à-vis the expected number of treatments for different kinds of illnesses. This lack of data is expected to impinge on the ability of insurance companies to determine the premium amount, and because the scheme is funded by the central and state governments, an inaccurate estimation of the premium could deal a significant blow to government finances.
Other concerns that have been flagged in relation to the implementation of this ambitious healthcare programme relate to private sector participants trying to push through treatments not covered by the insurance programme, thus nullifying one of the key objectives of controlling the cost of medical care. Already, private sector participants have expressed their grievances over the government’s pricing of packages, which they feel is too low and would not be tenable for complex processes such as bypass surgeries and caesarean sections, among others.
Questions also remain over whether HWCs would function effectively in their screening and delivery of primary healthcare, as they provide the screening and referral link between the beneficiary patients and Modicare. But most importantly, a factor often highlighted relates to the fact that while Modicare would cover the poorest 40 per cent of the population, a sizeable chunk of the population working in the unorganised sector, estimated to be around 50 crore people, would still miss out on the benefits of this scheme and remain at economic risk.
In this respect, it has been suggested that the Thailand model of universal healthcare be considered and lessons drawn from it. Thailand introduced a vastly acclaimed Universal Coverage Scheme (UCS) in 2001, which, in a decade’s time, covered 98 per cent of the population. The Thai programme covers outpatient, inpatient, and emergency care, with the services available anyone in need. This is in contrast to the Indian model, where outpatient costs have not been included in the insurance programme.
Furthermore, alongside a universal and comprehensive health benefit package, the Thais also invested significantly in ensuring that the quality of care was not compromised. An efficient system was evolved to weed out obsolete drugs, practices, and equipment and replace them with cost-effective drugs and global best practices. To further ensure that the benefits of the UCS reached every citizen, including those in remote rural areas, the Thai policymakers put in place a series of incentives for medical professionals serving in far-flung areas, in a bid to ensure that the tyranny of distance from urban developed centres did not hamper access to healthcare facilities or qualified professionals.
Information technology (IT) also plays a key role in the smooth functioning of the UCS, with district hospitals running their own hospital management systems. These are linked with the primary health centres, which also leverage IT applications to ensure that they are adequately stocked with supplies at all times.
Swarajya’s special mid-month issue for September, The Modicare Project, covers a range of stories on Ayushman Bharat and Indian healthcare. Catch it here.