Ayushmaan Bharat is a Great Distant Dream

Now that the hoopla over the launch of Modicare, the Pradhan Mantri Jan Arogya Yojana (PMJAY), billed as the largest healthcare system in the world, is over, a more detailed look is being taken to size up its pluses and minuses. Most of the initial comments are negative, arguing that in its present form it will not deliver. The biggest question mark raised by most analysts is over its funding. Mindful of this, finance minister Arun Jaitley has cited the ₹90,000 crore saved by going in for direct benefit transfer (DBT) and plugging leakages. This is quite true but it is not as if the savings from the DBT are lying in a special account and not currently being taking into calculating the fiscal deficit. So, spending on the PMJAY will be an additionality. What is more, expenditure of the states, which will have to foot 40 percent of the costs, will also shoot up. Those whose own running schemes are being merged with the PMJAY will see their existing cover in the region of ₹1-3 lakh per family going up to ₹5 lakh. To meet this additional expenditure they are likely to demand a bigger share of the economy’s pool of public resources. The arithmetic of the scheme is not even ready for sharing. For example, the premium that the government will pay the insurance companies will be market determined, through auction which is yet to take place.

If there are other scarcities which loom larger than that of resources, it is in healthcare infrastructure and skills needed for secondary and tertiary care. The PMJAY is going to give a massive boost in demand for in-patient care — hospital beds, well-equipped operating theaters and diagnostic labs. One of the pluses being touted for the scheme is that it will create a demand for secondary healthcare in small town and semi-urban areas where earlier people simply could not afford such care. True, but this will take time to come up — between one and three years. If you think this is daunting then look at the shortage of medical skills — doctors, nurses, lab technicians — outside of large towns and cities. The PMJAY will give a big boost to jobs for the educated middle class and is therefore to be welcomed. But for these skills to emerge you will have to first build the medical and nursing colleges which will then put people through courses. We are looking at a five-year perspective. So it will be years till the scheme gets going in any kind of size for it to call itself the largest in the world.

While the former are all operational issues, the most serious critique of Ayushman Bharat is structural. The PMJAY takes care of in-patient secondary and tertiary care and has hogged the limelight. The other part of Ayushman Bharat addresses primary care by setting up 150,000 health and wellness centers, which will deliver comprehensive healthcare close to people’s homes. These will also cover non-communicable diseases and maternal and child health, plus offer free essential drugs and diagnostics. Till now under 3000 of these have come up across the country and all 150,000 are targeted to be set up in four years. The primary focus of a sound health policy has to be keeping people healthy and, when they do fall ill, offer prompt care near to home so that very few need to get admitted for secondary and tertiary care. For people to be healthy, they need safe drinking water, proper toilets, an environment free of mosquitoes, adequate mother and child care and comprehensive immunization. The hype and hoopla ignores this other than building enough toilets under the Swachh Bharat mission. Even there, the emerging issues are: who will keep toilets clean, whether there is enough water to use in toilets and whether the waste generated is disposed of in a non-polluting manner.

It is a big thing for poor people to know that a big hospital bill will not create financial distress, but for that to happen, governance has to play a vital role. Keeping a control on over-billing and fraud by private hospitals will be a herculean task, if the experience over the Rashtriya Swasthya Bima Yojana (RSBY) is anything to go by. The government is laying great store by use of information technology, medical audit and patient feedback to address fraud and quality issues. These will help, but one solution is being downgraded. The best way to get private care to behave itself is to make it compete with a well-run public healthcare system. Tellingly, under the RSBY, more hospitalization took place in Kerala than in Jharkhand (the former had more well-run hospital beds to offer) but cost per hospitalization was lower in Kerala. It has the best-run public health service in the country, which prompts its private healthcare system to offer both quality and affordability. On the other hand, the PMJAY is based on the following logic. For 70 years we tried to create a public health service and look where it got us. So we will now pay for care only when it is delivered. – Money Control