ON September 23, 2018, Prime Minister Narendra Modi launched the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in Ranchi. Speaking at the event, Modi said that it was a “game-changer initiative to serve the poor” and that it was the biggest “government-sponsored health care system in the world”. Targeted at poor, deprived rural families and specific occupational categories of urban workers’ families, its stated aim is to provide them secondary and tertiary care such as advanced surgical interventions. The scheme, with a cover of Rs.5 lakh a family, is to benefit 10.74 crore families, approximating 50 crore beneficiaries.
In its 2014 manifesto, the Bharatiya Janata Party (BJP) promised to “Increase the access, improve the quality and lower the cost” of health services with the goal of providing “Health assurance to all Indians and to reduce the out of pocket spending on health care”. The promise remained only on paper until the very last year of the government’s term, when Modi announced the AB-PMJAY and personally launched it. In the five months that the scheme has been operational, besides gaps in its implementation, serious flaws have been detected that may eventually lead to large private hospitals and private insurance companies benefiting, with the government acting as a broker.
Take the case of Rajesh, 30, of Bagepalli near Bengaluru. A low-level government functionary with a few acres of land, he is exactly the vulnerable Indian citizen who has been identified as a beneficiary under the scheme. He dislocated his shoulder in February while working in his field. A couple of months earlier, in the end of December, he received his Ayushman Bharat-Arogya Karnataka (ABAK) card. Reassured that with this card he could get free treatment, he went to a private hospital in Kolar. He was turned away and was told that the card was not accepted there. Then he went to a private hospital in Bengaluru that is on the list of empanelled hospitals under AB-PMJAY. There, he was told that treatment for his dislocated shoulder was not covered under the scheme at the hospital.
Finally, he went to the government-run Victoria Hospital in Bengaluru, where he was asked to produce his below poverty line card besides his ABAK card. He was told that he would have to wait for 15 days for treatment as his case was not “urgent”. “I was fed up with all this. I went back to Bagepalli to a private hospital for treatment,” Rajesh told Frontline on the phone. “What is the point of these cards when they’re useless?” he asked.
Even when the scheme was launched, there was criticism by many opposition-ruled States. Karnataka, for instance, had a successful health coverage system under 10 separate schemes that had come into force over the past 15 years. Of this, the Yeshasvini Health Insurance Scheme (YHIS), which provided health insurance coverage to farmers for surgical procedures, was popular.
Karnataka eventually signed a memorandum of understanding with the centre after certain guidelines such as package amounts for surgery were changed. Under the AB-PMJAY, the Centre will contribute 60 per cent and the State the rest. The scheme, called Arogya Karnataka after existing schemes were merged with it, came into force in November 2018. ABAK cards were sent to the beneficiaries, who had been identified under existing schemes. But, as the case of Rajesh shows, the AB-PMJAY has not succeeded in helping vulnerable groups.
Dr Pavan Patil N., a general and laparoscopic surgeon running a private hospital in Gadag in north Karnataka, treats a lot of poor patients and is well aware of the functioning of health insurance schemes, including the AB-PMJAY. He identified three problems with its functioning. First, he said, middle-class patients who availed themselves of health care benefits under the various schemes in the past were unable to get the benefits of ABAK as they needed a referral from a government hospital, which is hard to come by.
The second problem was that the beneficiaries were unaware of the fine print of the AB-PMJAY. “They think that any treatment or surgery up to Rs.5 lakh is free, but this is not true. For example, if a woman undergoes a caesarean section while delivering a baby, the compensation is only Rs.7,000, which is unimaginably low. Beneficiaries, when asked to pay extra, end up at the doors of BJP politicians, who are also uneducated about the scheme. They shout at district health officials but when there’s no provision, what can the doctors do?” he asked.
The third and perhaps the most serious problem is that some ailments or parts of treatment that were covered earlier have been removed under the ABAK. “I have a patient who is suffering from ‘carcinoma rectum’ [cancer in the rectum]. Earlier, all stages of the surgery and treatment were covered, but now the closure of colostomy, which is the final part of the procedure, is not covered. What am I supposed to do as my patient, a 50-year-old woman who cannot afford the surgery, is running around with a colostomy bag?” he asked.
Dr Anil Kumar, a general and laparoscopic surgeon who is based in Bagepalli and associated with the People’s Health Movement in Karnataka, added: “We have to modify our medical treatment according to the provisions of the scheme. The insurance companies dictate to the doctor how the treatment should be done.” The number of empanelled hospitals has also come down. “Take my district [Chikkaballapura]: earlier there were 14 hospitals empanelled under the YHIS and 16 under the Rashtriya Swasthya Bima Yojana. Now the figure has come down to eight hospitals under the ABAK.”
A significant point of worry with schemes like the AB-PMJAY is that with the encouragement of health insurance models, governments move away from their responsibility of strengthening public health institutions. “Eventually, we will have a situation where government hospitals will be shut down and only insurance-backed corporate hospitals will thrive. Even small private hospitals will be driven out of business. In the long run, Ayushman Bharat will ensure that,” Dr Kumar said.
This is worrying, according to Sobin George, an assistant professor at the Centre for Study of Social Change and Development at the Institute of Social and Economic Change, Bengaluru. He said: “The move towards the insurance model is worrying as it weakens the public delivery system and promotes utilisation of facilities at private hospitals. There is an overdose of medicalisation as the patients are insured. This only leads to a maximisation of profit of private hospitals and private insurance companies without strengthening the public health system. Funds that were earlier used for public health are now only profiting big insurance companies.” George also dismissed another argument that under health insurance schemes such as the AB-PMJAY, access to private hospitals would provide a larger number of health facilities. “This is a flawed argument as the nearest empanelled private hospital in a rural area is usually at the district headquarters and at least 50 to 100 kilometres away.”
The shift towards disinvestment in public health is also reflected in budgetary allocations which have fallen since the National Democratic Alliance government came to power in 2014. Over the past few years, the Central government’s Budget allocations for health have hovered between a measly 0.25 and 0.3 per cent of gross domestic product. This figure has been cited in Indranil Mukhopadhyay and Dipa Sinha’s essay “Painting a Picture of Ill-Health”, which is featured in the book A Quantum Leap in the Wrong Direction? . The duo’s essay also makes another valuable point with regard to the AB-PMJAY when, after a careful analysis of the latest Budget, they raise doubts about whether the allocation is even sufficient to meet the lofty claims of the scheme.
