Overcoming the challenges in creating a nationwide health infrastructure will take several years.
It has many names, official and unofficial: Ayushman Bharat Yojana for the Hindi heartland, National Health Protection Scheme or NHPS outside it, and Modicare for the BJP propaganda machine, which seeks to build a second Modi wave before the 2019 general elections. In case you forget that it’s about elections, it’s also called the Pradhan Mantri Jan Arogya Abhiyan.
The plan is typical of the Modi road to Achhe Din/New India: a big idea, an impossible-sounding target, promise of an overnight revolution, a hurried launch on 25 September, poor attention to detail, and selling a new dream. In the end, it will be spun as good intention. At least he’s trying, we’ll be told in poor defence of the scheme.
India’s public health infrastructure is as good as non-existent. With just 1 per cent of the GDP spent on the sector, India has one of the world’s lowest investments in healthcare. The unmet need is so huge that insurance is, logically, the only solution.
The government can give every Indian a health insurance overnight with tax payer’s money, no problem. People will now have the means to be treated in hospitals. What overnight insurance won’t solve right away is the supply gap: the doctors, the hospitals and the medical staff.
Supply will follow the demand gradually. This will take many years. Then there will be bottlenecks, regulatory issues, fraud and so on. Solving those will take a long time.
“There is a provision of giving five lakh rupees per annum health assurance for each family,” the Prime Minister said in his Independence Day speech. It sounds as if every family’s going to get benefits worth Rs 5 lakh right away, or at least that’s how the BJP is going to make it sound like over the next few months.
‘Paanch lakh, paanch lakh’, they’re going to go from house to house, screaming out loud. You’ve already got it, without even applying, they’ll be told. The Prime Minister may write to each one of the 10.74 crore families selected using the 2011 Socio-Economic Caste Census data. The 50 crore people that the scheme aims to target is more than enough to ensure a second term for Modi.
It is only after they have voted in April-May 2019 that people will realise the supply side problem. There won’t be enough hospitals to take care of the sudden surge in demand for hospital beds and specialist doctors.
Even without the massive surge in patients that Ayushman Bharat is likely to result in, India is severely short of doctors, paramedic staff and hospital beds. India has one (allopathic) doctor per 1,596 people, as against the World Health Organisation-prescribed figure of 1 doctor per 1,000 people.
As for government doctors, the ratio stands at 1:11082, highlighting a shortage so massive that it makes insurance for the poor a no-brainer. Insurance will make private doctors and hospitals accessible for the poor. But the health infra won’t come overnight.
The government says it has received around 7,000 applications for empanelment. How many hospitals are finally empanelled with Ayushman Bharat will be a matter of keen interest in every district of the country. The challenge is particularly acute in Uttar Pradesh, Bihar and the northeast. Big hospital chains are staying away for now, preferring to wait and watch.
People will be told Ayushman Bharat has solved their health woes. When they queue up at the private hospitals, they will realise that a piece of paper takes a while to translate into actual treatment. There will be long waiting period, and huge queues. It’s not Modi’s fault, it’s the doctors and the greedy hospitals, they will be told.
Ayushman Bharat is a good beginning but it’s the beginning of a long process. Sadly, it will be sold as a one-shot panacea, a jadi booti that you mix with your vote and drink and your health woes will be solved. That is why it won’t be unfair to call it a jumla, a mere sentence not meant to be taken literally.
What should the government do?
First, it should lower expectations from Ayushman Bharat, undersell it rather than overhype it.
Second, the government has to come up with an action plan to increase medical infrastructure in the country, particularly at the sub-district taluka or tehsil level. How are we going to get the massive number of doctors, hospitals and paramedic staff overnight? The insurance itself is not enough. The government still needs to substantially increase the health budget to help build health infrastructure.
Third, the government must make sure doctors and hospitals are happy with the rates it sets. Low rates won’t incentivise them. Remember we are competing to prevent these doctors from immigrating to the West. Low rates will also increase the incentive for fraud, which is a huge problem in government-backed insurance.
Fourth, the government must increase investment in primary healthcare, giving free diagnosis and medicine to the poor. Not doing so makes the illness grow to a proportion where they need to be hospitalised. Ayushman Bharat may make such hospitalisation possible, but prevention is better than cure, especially when the country’s health infrastructure is woefully inadequate. A good model to study is the Delhi government’s mohalla clinic.
Fifth, the very poor may not be able to afford proper medical treatment despite having Ayushman Bharat insurance coverage since there is other out-of-pocket expenditure, which hospitalisation entails. There are transport costs, loss of wages, pre- and post-hospitalisation expenses. This has been the experience with the Rashtriya Swasthya Bima Yojna, and the Ayushman Bharat has not been designed to address this problem.
Sixth, most states seem to be opting for the ‘trust’ model instead of private insurance companies to implement Ayushman Bharat. In the trust model, the government sets up a trust that acts like the insurance company. They are doing so for the fear of high rejection of claims by private insurance companies. But this also takes away a layer of protection against fraud. The government must therefore find a way of involving private insurance. Perhaps, the hybrid model that states like West Bengal and Gujarat are adopting is the best. This model gives insurance worth Rs 50,000 to private insurance companies, but claims above that come to the government-managed trust.
Seventh, the government has allotted Rs 10,000 crore for Ayushman Bharat, presuming an annual premium of Rs 1,000 per family. But health insurance for the poor in states like Rajasthan has suffered from high claims, high fraud and thus, rising premiums because the government doesn’t like to see high rejection rates. So, the government will have to be ready to see the premium amount rise. Key to any preventive action will be checking fraud, which the government says it will do with the use of technology.