Is Ayushmann Bharat a quantum leap in wrong direction?

India ranks poorly at 145 out of 195 countries in Healthcare Access and Quality(HAQ) Index published by Lancet.Its rank is worse than our neighbours like Bangladesh,Srilanka and some of the Sub-Saharan African countries. On one hand, India has emerged as most sought after destination for medical tourism.On the other hand,It has failed to provide essential healthcare to vast majority of its population.Therefore Indian healthcare scenario can be called as islands of California in a sea of Subsaharan Africa.
The Ayushmann Bharat(AB) scheme has been introduced to comprehensively address this gap.This will cover 10 crore poor and vulnerable families(approximately 50 crore beneficiaries)with coverage upto 5 lakh rupees for secondary and tertiary care.It is a publicly funded private insurance scheme.70 percent of healthcare in India is provided by private sector.This scheme is meant to make that seventy percent cater to poor people through public financing.

This scheme has been hailed as a gamechanger by the government.But many concerns with respect to its design and implementation exist.This piece will discuss them in brief.

• Fund allocation:The budget allocation is just 3200 to 6400 crore.Even if we make modest estimates, it is highly insufficient.Even if the claim rate is just 10% at an average of 10 percent of maximum limit of 5 lakh,it comes to 50000 crore.(10% of 10 crore=1 crore,10% of 5lakh=50000,finally 50000*1crore=50000 crore)
• Low and unviable rates: The Ayushmann Bharat rates are very low and are not economically viable for private hospitals.They are lower than CGHS rates,which are already very low.
• Lack of private sector participation: 70 percent of healthcare in India is provided by private sector.One of the basic intention of Ayushmann Bharat was to make this 70 percent sector cater to poor through publicly financed insurance scheme.Due to low and unviable rates,private sector has shown no interest.Over the top of it,delay in payment to private hospitals and bureaucratic redtape seen in previous central and state schemes discourage private sector participation.As a result government has empanelled State government run hospitals and Railway Hospitals under AB to show it as a success.This defeats the very purpose of the scheme.
• Overreliance on Private Insurance:The dependence on private sector for providing care to poor has its own limitations.This has been analysed as “Private Insurance Trap” by Amartya Sen in his book “An Uncetain Glory:India and Its Contradictions”.

  Private Insurance Trap happens because:
>> The system gets biased against Preventive and Non Hospitalise Care.There will be distortion towards In-Patient Care.
>> Moral Hazard:Private hospitals have little incentive in containing the costs.Risk of excess and unnecessary treatment exists.Malpractices in accounting will be rampant.
>>Issue of correctly targeting the poor and exclusion of genuine beneficiaries can occur.
>>Irreversibility:Once private Insurance model is launched,it cannot be rolled back even if it proves to be a failure because of development of powerful lobby by private hospitals.This is evident in USA.These concerns are legitimate. Overreliance on publicly funded private care will lead to negligence of public health infrastructure,which will have its own bad consequences.

• No major push towards Strenghthening of Government Hospitals.We need more schemes like PMSSY(PM Swasthya Suraksha Yojana) to upgrade government hospitals

Because of these concerns,many analysts have called Ayushman Bharat(AB) a quantum jump in wrong direction,that needs course corrections.


Doing What Really Matters:
UK model of National Health Service(NHS),dominated by public healthcare suits country like India better than Private Insurance model of USA.

• Enhancing Public Health Expenditure: Current Public Health expenditure is just 1.25%.Successive governments want to give World Class Universal Care without spending any money.Promises in air(Ayushmann Bharat also joins this list)have become the norm.Drastic increase in Health expenditure to 2.5 to 3% of GDP is needed(WHO recommended-4 to 5%).This is the single most change that can prove that government is serious about healthcare rather than use it as electoral gimmick.
• Strengthening public health infrastructure: Government hospitals should be strengthened with adequate manpower,high quality medicines and equipments.In such place,any poor,destitute can walk in without documents and take quality treatment.It will also help to focus on preventive and community health aspects.PPP Models should be used to upgrade government hospitals.
• Publicly funded private care: Such publicly insured private care(Ex AB,RSBY,Yashaswini scheme of Karnataka etc)should act as complementary to government hospitals to infuse sense of competition and efficiency.They should not be thought of as replacement to government hospitals,as it may lead to private insurance trap as explained above.The rates should be fixed at viable market rates.Innovative mechanisms should be designed to counter malpractices in accounting and care.
• Incentives for Healthcare Professionals: A recent ad by Karnataka Government that has 50000 salary for a Super specialist doctor depicts absurd and sorry state of affairs. People with Ten to Four clerical jobs in cities are paid more than healthcare workers who put in extra hours routinely with all kind of risks.Salary and working conditions should improve.Safety of healthcare professionals has become a major national concern.It should be addressed holistically.
• All India Medical Service: An All India Service on the lines of IAS and IPS should be created for better implementation and monitoring of Heath Programmes.This will lead to better convergence between Central and State initiatives.Current arrangement,where generalists are at the forefront of health policymaking and implementation has caused enough damage.Doctors trained in administrative affairs should be given enough powers with accountability fixed for healthcare outcomes.

These components should be integrated into Ayushmann Bharat to make it really gamechanging rather than just focussing on publicly funded private insurance.Poor and middle class should have good government hospitals and publicly funded private care to access,while rich can go to world class corporate hospitals with their own health insurance.
Economist Amartya Sen has once remarked,India is the only country trying to become a global economic power with an unhealthy,uneducated labour force.Its never been done before,never will be done in future either.All the advanced coutries today like Europe,Japan,US,Singapore etc invested heavily in Health and Education before they took off their economy to greater heights.States like Kerala,Tamilnadu,Delhi have shown enough promise in this direction.
Our Prime Minister’s dream of making India a 5 trillion dollar economy by 2022 and make it a Vishwaguru(global leader) is not possible if we don’t focus on Health and Education on mission mode.