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Only one Government Doctor Per 11,000 People, is Ayushman Bharat the Answer?

On August 15, Prime Minister Narendra Modi announced the NDA government’s flagship project: Ayushman Bharat, a government-sponsored health insurance scheme which seeks to provide free medical coverage of ₹5 lakh per year per family at any public or select private hospitals across the country. He said the program would be launched a month later on September 25. Deemed as the world’s largest government-funded healthcare program, the ₹10,000 crore-strong initiative, he declared, “aims to cover more than 10 crore poor and vulnerable families (or, 50 crore people) for secondary and tertiary care hospitalisation, the premium of which will be shared by Center and states in 60:40 ratio”. But in a country like India, where on average a population of 11,000 is tended by just a single doctor, and the non-availability of health services in remote areas remains a concern, will the much anticipated Ayushman Bharat scheme foster a change in an already ailing healthcare system?

What it promises

Besides the insurance coverage, the National Health Protection Scheme (NHPS) aims to build a next-generation primary healthcare system by upgrading 1.5 lakh sub centers (SCs) into health and wellness centers. The plan is to deliver a larger and comprehensive package of primary healthcare at the grassroots level at locations close to the community. This scheme is critical for attaining a Universal Health Coverage (UHC), which coincidentally is the theme of World Health Day 2018 and one of the Sustainable Development Goals (SDGs) — a plan of action for people, planet and prosperity to be achieved by the member countries until 2030. Unlike any other medical insurance, this scheme aims to nullify any waiting period for pre-existing diseases and envisage a benefit cover of both pre and post hospitalization expenses along with transport allowances for people listed in the Socio-Economic Caste Census (SECC) database.

So Far, So Good

The Ayushman Bharat scheme doesn’t require the 50 crore beneficiaries to shell out any money, but the premium of the insurance cover has to be shared between the Center and the states. All the states, except Odisha, have signed the Memorandum of Understanding (MoUs). While West Bengal, Jharkhand and Nagaland have gone for a traditional insurance model where the state pays premiums to an insurance company just like one pay to a health insurer. Others, like Uttar Pradesh, Uttarakhand, Tripura and Himachal Pradesh have opted a Trust model, where the premium won’t be paid to an insurance company, but will be pooled into a trust which not only will manage and administer the health scheme but also pay the claims. Despite the nation’s long struggle with diseases like tuberculosis, malaria, dengue, diabetes and cancer, the government had, by far, neglected the healthcare: one of main reasons of poverty in India. The country has dedicated a mere 1 percent of GDP towards the cause, which is far less than the global average of 6 percent.

The next-generation primary healthcare system under the Modicare envisages population-level screening to detect diseases early and initiate timely treatment, which might help curb the rising burden of non-communicable diseases (NCD). More importantly, the National Health Agency (NHA) and the ministry of health & family welfare (MoHFW) have cleaned up the beneficiary database, created an IT backbone, set the guidelines in place and got the state governments in agreement with the proposed healthcare program. Further, the scheme ensures a medical cover for all by not placing any cap on the 10.5 crore family size or age — and neither is there any exclusion to be made if a person is suffering from pre-existing disease condition. The government has identified about 1350 common medical packages, covering surgery, medical and daycare treatments. Moreover, with over 8000 hospitals already having offered to join the list of empaneled facilities, the scheme sure looks optimistic on paper.

The loopholes

The shortage of workforce is one of the most important reason why there is a non-availability of health services (especially curative) in remote areas. According to the National Health Profile (2018), one allopathic government doctor in India, on an average, attends to a population of 11,000 people. This is 11 times more than the WHO recommended a doctor-population ratio of 1:1000. Further, there is an unequal development of health infrastructure and under-developed health facilities in many states. The situation is worst in Bihar where one doctor serves a population of 28,391 people, followed by Uttar Pradesh with 19,962 patients per doctor. Meanwhile, another grave area of concern is the inadequate number of hospitals: a total of 23,582 hospitals having 710,761 beds is abysmally low in a country with 1.3 billion population. On an average, a government hospital bed caters to 1908 people in India. The situation, again, is worst in Bihar where 8789 share a bed; in Jharkhand, the ratio stands at 6502:1.

The sub-centers, which the Modi government aims to convert into health and wellness centers under the NHPS, ails under poor infrastructure and the lack of staff and equipment and medicine. Only 11 percent of the 1.56 lakh sub-centers met the Indian Public Health Standards by March, 2017, the rural health statistics released by the health ministry found. Moreover, 20 percent of them do not even have regular water supply and 23 run without electricity. A total 4243 centers were without any Auxiliary nurse midwife (ANM) or a male health worker. A failure in providing curative care at government-run rural healthcare system often results in the crowding of sick persons at urban facilities, which are mostly private sector, and an increase in the out-of-pocket expenditure (OOPE) in the form of travel, lodging, and loss of wages.

The previous Rashtriya Swasthya Bima Yojana (RSBY) state-run insurance program didn’t quite manage to control the OOPE or increase access to healthcare for poor. Several analyses have highlighted that despite the increased insurance coverage, it still was out of bounds for the poor. One such showed only 1.2 percent the hospitalization cases of the rural population and 6.2 percent of the urban population received even part reimbursement. In India, 67 percent of all expenditure on health is out-of-pocket and of this, 63 percent expenditure is on out-patient. NHPS, in the current format, focuses on secondary and tertiary care services which are concentrated mainly in urban areas. With the primary care in shambles, the scheme would fail to check the movement of patients from rural areas to urban centers and thus may not make a significant dent to the OOPE.  – News18

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