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| EDITORIAL |
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| Year : 2019 | Volume
: 24
| Issue : 2 | Page : 65-67 |
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Ayushman bharat and road to universal health coverage in India
Vikash R Keshri1, Subodh Sharan Gupta2
1 The Centre for Health Policy, Asian Development Research Institute, Patna, Bihar, India
2 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| Date of Web Publication | 17-Sep-2019 |
Correspondence Address:
Dr. Subodh Sharan Gupta
Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmgims.jmgims_44_19
How to cite this article:
Keshri VR, Gupta SS. Ayushman bharat and road to universal health coverage in India. J Mahatma Gandhi Inst Med Sci 2019;24:65-7 |
The World Health Organization defines universal health coverage (UHC) as means to enable all people and communities to use promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. It embodies three objectives: equity in access, quality, and financial risk protection.[1] The UHC movement received more impetus after it was included as one of the targets of the United Nation's Sustainable Development Goals-3 (SDG-3) in 2015.[2] Many low- and middle-income countries have started special programs, mainly different kind of health financing and insurance schemes in aspiration to move toward UHC.
In 2018, the Government of India launched an ambitious health-care scheme known as “Ayushman Bharat” (long live India), widely projected to be a progressive step toward UHC in India. The Ayushman Bharat scheme essentially has two components: Pradhan Mantri Jan Arogya Yojana (PMJAY) and Health and Wellness Centres (HWCs).[3] The PMJAY is a publicly financed health insurance scheme for the socioeconomically deprived rural and selected occupational category of the urban population. It aims to cover 100 million households and approximately 500 million people of the country, which roughly accounts for 40% of the total population.[4]
As per the Constitution of India, health is a subject matter under the jurisdiction of state governments. Therefore, the health systems in different states have developed heterogeneously due to the influence of the prevailing political economy. Conventionally, the expenditure on health care is also very dismal. The overall health expenditure in India was 3.8% of the total gross domestic product (GDP), and the government's contribution was nearly 1.18% of GDP in 2015–2016. The household health expenditure comprised 64.7% of the total health expenditure, and out-of-pocket expenditure (OOPE) was around 60.5% of the total health expenditure. The expenditure on primary, secondary, and tertiary care is 45%, 35%, and 15% of total health expenditure, respectively.[5] According to a report, nearly 60% of total OOPE is incurred on outpatients care only.[6]
| Pradhan Mantri Jan Arogya Yojana: Opportunities And Challenges | |  |
The stated objective of PMJAY is to provide access to good-quality health care service without anyone having to face financial hardship. The scheme envisages reducing OOPE and catastrophic expenditure on health care through participation of private sector in addition to the existing network of public hospitals.[4]
The benefits package under the PMJAY includes cashless treatment up to 500,000 rupees per family per year on a family floater basis. Around 1350 medical and surgical procedure are included under the scheme which is claimed to include almost all secondary and most of the tertiary care procedures. It allows the beneficiaries to avail free services from either public or an impanelled private hospital. All preexisting diseases are also covered, and the hospital is not allowed to charge any fee.[4]
Apparently, it seems that PMJAY can potentially reduce the incidence of catastrophic health expenditure for a small proportion of households. Although its impact on reducing the OOPE will be very limited owing to the fact that currently 60% of OOPE is incurred on outpatient care, which is not included in the scheme.[6] PMJAY can probably be helpful for chronically ill patients from lower socioeconomic strata requiring frequent hospitalized care or expensive procedure such as dialysis. It can also incentivize the existing secondary and tertiary care public health facilities by infusing more insurance claim money. In the long run, this scheme has the potential to enable the growth of the private sector in second- and third-tier cities, thus giving the rural Indian more choices. Along with these possible prospects, the PMJAY also faces multiple challenges.
Around 25% of the country's population was already covered by a health insurance scheme in 2015–2016, mostly by any publicly financed schemes. The interstate variation in health insurance coverage ranged from 75% in Andhra Pradesh (including Telangana) to around 6% in Uttar Pradesh. Interestingly, the disparity in health insurance coverage among different income category of households was not much.[7] Therefore, the PMJAY with its target beneficiaries of around 40% of households can increase the coverage in some states but only marginally. It also leaves a large section of the population uncovered, thus exposing them to the risk of catastrophic health expenditure. This will defeat the spirit of the central pledge of “leaving no one behind” while implementing SDG.
The extent and distribution of health facilities for secondary and tertiary care level in public as well private sectors are very uneven. According to a recent study, the number of private hospitals in health insurance network in Bihar was 253, whereas in contrast, Maharashtra has >3000 private hospitals in the network. Bihar and Maharashtra contribute to 10.4% and 8% of total beneficiaries of PMJAY, respectively. More importantly, around 65% of the private hospitals in the country have strengths of 11–50 total beds, which can significantly limit their ability to function as a tertiary care center.[8]
Another much-lauded feature of PMJAY is the portability of benefits across states. However, due to the uneven distribution of health facilities across states, this feature of the scheme can significantly complicate the future development of health-care infrastructure and health systems. The relatively better treatment facilities available in better-performing states of the country are likely to attract more patients from states with inadequate facilities. This may result in two possible scenarios. In the first scenario, the health facilities in better-performing states may not be able to cope up with increased load of patients, and quality of services get compromised. In the second scenario, if the health system in the better-performing states is able to cope up with increased service demand, then it will lead to the transfer of funds spent on the scheme from poor-performing states to the better-performing states. In the long run, the health infrastructure in the better-performing states will get further boost utilizing resources from the poor-performing states, thus widening the inequity between states. In both of these scenarios, the poor-performing states will end up having limited capacity for infrastructure development and overall health system strengthening.[9]
The simultaneous implementation of the scheme in a similar fashion across all states can prove to be another challenge. Due to limited overall governance and program implementation capacity in many states, the implementation can be derailed. Some of the large states, especially UP, Bihar, and Madhya Pradesh, do not have any prior experience of implementing a health insurance scheme of this scale. Like all previous centrally supported scheme, this scheme can also end up creating more interstate divide in making an impact.
Engaging with the private sector in near-complete absence of regulation and “laissez-faire” health-care market is another significant challenge. The Clinical Establishment Act, 2010 with the mandate to register and regulate health facilities have failed miserably in regulating the private sector in ten states and Union Territories, where it was implemented. Other states have diverse form of regulatory policies with variable outcome.[10] The absence of standard treatment guidelines (STGs) and protocol and evidence of irrational practices can be one more important bottleneck. In the absence of the robust regulation and STGs, the cost of care and overall budget for the scheme may rise steeply in due course of time.
The amount allocated to PMJAY in two subsequent annual budgets (2018–2019 and 2019–2020) is also proportionately much lower to cover the targeted 40% of the population of the country. Around Rs. 3200 crores were allocated for the scheme in the 1st year and Rs. 6400 crores in the subsequent year. Even if only 5% of the beneficiary families claim 20% of the insurance amount (i.e., Rs. 5 lakh) which they are entitled to, the estimated expenses would be Rs. 50,000 crore per annum, without accounting for the running cost of the scheme.[11]
| Health And Wellness Centers: Opportunities And Challenges | | |
The HWCs are envisioned to be a step to overhaul the primary health-care delivery system in India. Around 150,000 HWCs are to be created by transforming the network of existing Sub-Centre (SC) and Primary Health Centre (PHC). This corresponds to nearly one HWC for 8500 people. Two different types of HWC are envisaged for SC and PHC level. The HWC at SC level will be manned by a group of multipurpose workers (male and female) and a new cadre of health provider called Mid-level Healthcare Provider (MLHP). These MLHPs can either be a community health officer (BSc. Community Health) or a nurse (BSc. or GNM) or an AYUSH practitioner. The HWC at PHC level will be manned by human resources as per existing norms. The service package includes all essential services of existing PHC with the notable addition of prevention, screening and management of noncommunicable diseases, mental illness, common ophthalmic and ENT problems, basic oral health care, and care of elderly and palliative health-care services.[12]
The objective of HWC is very ambitious and seemingly difficult to be achieved. The roadmap for HWC is too simplistic and devoid of learning from the historical pathway of health systems development and its existing complexities. Unlike all other national-level initiatives, it also ignores the heterogeneity of the development level of states and its health systems. The recommendations of the Bhore Committee regarding the distribution and coverage of primary health-care facilities could not be fulfilled by many states even today. The challenges to ensure primary health care have only increased over the period of time. How the HWC initiative will address and overcome these challenges is not explicitly stated.
In conclusion, the objectives of Ayushman Bharat are ambitious and the implementation seems to be hasty. PMJAY scheme also poses threats of diverting limited resources available for health in undesirable directions: (1) from public sector to private sector, (2) from preventive and promotive health services to predominantly curative services, (3) from primary health care to secondary and tertiary care services, and (4) most likely from poor-performing states to better-performing states. It must be realized that a simple solution, in the form of shifting responsibilities of the public health care system to the private sector, does not exist for the woes of the health system in the country. For a scheme of the nature of Ayushman Bharat, the responsibilities of the government further expand to include putting in place complex regulatory framework for the private sector, establishing ombudsman to protect the rights of the people vis-à-vis the health insurance providers, and the preparedness of the system to deal with challenges as they arise. In the absence of a clear blueprint to address the existing challenges of health systems in the states of India, the outcome of reform of such magnitude is hard to forecast at this time.
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| 8. | Choudhury M, Datta P. Private Hospitals in Health Insurance Network in India: A Reflection for Implementation of Ayushman Bharat. NIPFP Working Paper Series, No 254. National Institute for Public Finance and Policy; 2019. Available from: https://www.nipfp.org.in/media/medialibrary/2019/02/WP_254_2019.pdf. [Last accessed on 2019 July 25]. |
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