Enhancing the success of the Ayushman Bharat for inclusive healthcare

On September 23, Prime Minister Narendra Modi, launched the Pradhan Mantri Jan Arogya Yojana (PMJAY)-Ayushman Bharat and termed it a “game-changing initiative to serve the poor”. The scheme aims to provide a health insurance cover of Rs. 5 lakhs per family, every year, and will benefit over 10 crore households. Earlier in the year, the World Health Organization’s Director General had praised the program for its scope of ambition and boldness. However, calculations bear out certain obstacles to a smooth implementation.

Availability of Finance

The financing of the scheme is by 1% cess, which is expected to collect an amount of Rs.11000 crore to the exchequer. If even 10% of the sum insured is claimed it will produce a bill of Rs. 50000 crore to the government. The government will have to resort to a reliable source of finance to make the PMJAY successful. Five states have already opted out of the scheme – Delhi, Kerala, Odisha, Punjab and Telangana.

Create a New Consolidated Health Insurance PSU

It is not clear so far, which insurance company will be an insurance provider for PMJAY. Health insurance should, ideally, be kept in the public domain and a new company for this purpose (by merging the health insurance division of the three insurance providers in the public sector) should be created. This company can create various insurance products, for different kinds of payers. Scale economies will generate low cost products, which would enable people to largely bear the cost of insurance. Poor and marginalized populations, in that case, can also pay part of the premium.  

Frame a Strong and Resilient Digital Backbone

In July, 2018, Niti Aayog issued a document called ‘National Health Stack’ as a first step towards ‘Ayushman Bharat’. ‘The National Health Stack (NHS) is a visionary digital framework usable by centre and states across public and private sectors. Through this platform, digital health records for all citizens by the year 2022 will be stored in a database’. Through this platform, national health electronic registries, a coverage and claims platform, a federated personal health records framework, and a national health analytics platform will be made possible. A strong and resilient digital backbone to the health system will bring transparency, and will enable the process of shifting from illness-focused to a wellness-oriented approach and to ensure cost-effective healthcare. With the help of this kind of data, specific customized solutions can be developed for the people at the local level. Technological innovations like telemedicine, gene mapping, large scale diagnostic labs etc. will enable health systems in the country to leapfrog to a more vibrant and sustainable health care delivery system. Although, a large population is to be served, it also gives opportunity in terms of scale economies, because the per person cost of technology is minimal.

Strengthen the Gatekeeper for Health Services

Effectiveness of primary healthcare centers is the key to the success of Ayushman Bharat. Gate-Keeping in healthcare systems, is a mechanism of care referral where a general practitioner is the first point of contact in the patient’s care path and thus controls the patient’s entry into the health care system. In our country, gatekeepers would be physicians or nurses in PHCs and CHCs. Referrals from these centers to an empanelled PMJAY hospital, will be the starting point of the chain in this scheme. Ability of tertiary care hospitals in public and private sector, to take the patients who have a PMJAY card, and providing them cashless treatment would complete the process. Studies have shown that patients get referred to private sector hospitals, as government hospitals are overcrowded and there is a lack of trust at the user’s level.

Increase Density of Healthcare Providers and Personnel

There are significant infrastructural gaps in India, as far as health care delivery is concerned. There is a normative gap of 3,469 community health centers for a population of 0.1 million, 5,887 primary health centers for every 30,000 people and 27,430 sub-centers for every 5,000 people.  Even if these facilities exist, they are not fully equipped. There is a gap in the number of doctors, nurses, paramedics, and frontline health workers required to run this system as well. Because of this gap at the lower levels, a referral system cannot be created and hence, the burden is shifted to tertiary level hospitals and medical colleges in the district. 

Make Reimbursements Feasible for Greater Participation

Private hospitals are not comfortable with the cost of care estimated under PMJAY. A delegation of private players had given a representation at Niti-Aayog in this regard. They find the rate too low. However, there are reportedly 9000 private hospitals empanelled with PMJAY. Putting too much of money in insurance, considering wide gaps in government infrastructure will transfer committed funds to private sector every year. Capital Expenditure on health will get a boost in the private sector, but it will also give rise to cost of care, drugs, and diagnostics. Very strict regulations and constant negotiations with the private sector to bring down the cost, will make this public private machinery work, otherwise it will give rise to various un-ethical practices. Privatization of a basic service like healthcare, brings up unique inequities, like it is in US, those who can pay have a better access to health. Forcing private sector to prioritize the poor is a sound maxim, but government will have to generate economies with which it would work. 

Maintain Efficient Management Practices in Government Hospitals

The last initiative would be improving the management of hospitals. Government Hospitals are very poorly managed, and the reason often cited is the over crowdedness of the hospitals. Military hospitals in India are equally loaded, a doctor sitting in an OPD, in a military hospital usually entertains, the same number of patients.  OTs, wards and other services are also equally in demand. The difference lies in the management. Military hospitals are managed efficiently, SOPs are followed and monitoring and regulation is very strict. The same can be done for government hospitals too. 

About Author: Dr Monika Chaudhary, Associate Professor, IIHMR University, Jaipur. She is a postgraduate in Economics, MBA in Finance and PhD in International Trade and Finance from University of Rajasthan. She was selected for Rajasthan State Administrative Services, but she found her true call in research and academics.