The Ayushman Bharat Yojna (or Modicare), Prime Minister Narendra Modi’s ambitious centrally-sponsored healthcare scheme, was announced in September 2018, mere months before the Lok Sabha polls.
Projected by the Modi government as a purported game-changer for the Indian healthcare system, the Ayushman Bharat scheme has come in for as much praise as flak from healthcare and associated sectors. Where exactly does the scheme situate the government weeks before from the general polls in which Modi is seeking re-election?
Understanding Ayushman Bharat
The Ayushman Bharat scheme was announced as an embodiment of ‘the new India 2022 vision’ in the 2018 Budget speech. It was to include two major initiatives—the creation of health and wellness centres (HWC) and a National Health Protection Scheme (NHPS).
Ayushman Bharat aims to provide a cover of Rs 5 lakh per family per year and is likely to benefit more than 10 crore poor families—or over 50 crore people—across country for secondary and tertiary care hospitalisation, through a network of 16,000 government and private hospitals. This coverage extends to facilities such as emergency medical services, management of communicable and noncommunicable diseases and general outpatient care, as well as reproductive, maternal, neonatal, paediatric and adolescent health services.
The HWCs are to include point of care, wellness room for yoga and physiotherapy, a private consultation space, free diagnostics and pharmacy, facilities for telemedicine, and waiting area for 30 plus persons.
How does Ayushman Bharat fare?
Touted as the world’s largest government funded healthcare program, Ayushman Bharat got off to a steady start in late 2018. About 6.85 lakh people have been provided hospital treatment under the scheme in the first 100 days since its implementation.
At that time, Finance Minister Arun Jaitley had said: “5.1 lakh claims have availed of the scheme, for which payment has been released. This averages 5,000 claims per day for the first 100 days. No patient has had to pay a single rupee.” He further went on to say that since 62.58% of the population has to foot their own healthcare bills, with most finding it unaffordable, the Ayushman Bharat scheme is a “game changer”.
Given the extent of financial coverage provided and the number of people covered under the scheme, such a government mandated measure is truly unprecedented. The logistical challenges of implementation are in turn counterbalanced by large scale digitalisation of healthcare information through a comprehensive IT system that is being put in place.
Gujarat has led the way among the states with increased instances of implementation, accounting for around 26% (76,000) of the total number of hospital admissions cleared under the scheme. Tamil Nadu (54,273 hospital admissions), Chhattisgarh (53,180 hospital admissions), Karnataka (40,216 hospital admissions) and Maharashtra (27,237 hospital admissions) follow.
The scheme was allocated Rs 6,400 crore in the 2019 Budget, an Rs 2,400 crore increase from the previous Budget. An additional Rs 156 crore will be diverted from the budgetary allocation for the Rashtriya Swasthya Bima Yojana (RSBY), Ayushman Bharat’s predecessor. Increased government spending on a sector that has historically been neglected by the Indian state bodes well for the general restructuring of the healthcare sector.
Despite the rosy picture the Ayushman Bharat scheme paints, it has drawn strong criticism from healthcare professionals and policymakers alike.
This is mainly due to the nature of impact the scheme has had, and will have, on the healthcare sector. The overriding argument is that the extent of its applicability—and success—is dependent on the condition of the public healthcare systems in each states.
The scheme identifies 62.58% of the total population (roughly 132.42 crore) as “not covered through any form of health protection”. However, only 38% of the population, or about 50 crore people. are covered under the NHPS. This means that about 32.87 crore people remain beyond the ambit of the scheme.
Although the Ayushman Bharat scheme aims to provide healthcare support to a considerable section of the population, it has been argued that the financing only ends up benefitting the private sector, given the grave condition of the public healthcare system.
The Indian Constitution provides for the right to healthcare for all citizens, with the responsibility on individual states.
States with an underdeveloped public healthcare systems such as Jharkhand and Chhattisgarh stand to suffer more from the Ayushman Bharat scheme due to the lack of regulation in its healthcare industries, the relative lack of private health providers in non-urban areas, and the levels of development in each state compared to others.
According to health activist Kumar Rana, the quest for profit could lead to “health insurance abuse through plundering of the public exchequer and also by encouraging many other unethical practices” in “states with poorer health delivery mechanisms”.
The scheme also makes no provisions for improvement of public hospital infrastructure. The money provided, albeit unprecedented in comparison, allows patients to access healthcare facilities that are lacking in most public hospitals. As a result, the population targeted will mostly end up accessing private facilities.
In such a scenario, the government ends up being the financier of healthcare rather than the provider.
Former Union Secretary for health K. Sujatha Rao argues that in addition with greater focus on secondary and tertiary medical care, Ayushman Bharat stands to deepen scope of privatisation in the healthcare system. According to Rao, the private healthcare sector tends to overcharge, over-diagnose to increase profit margins, which could be extremely problematic with increased dependence on the sector, given lack of regulation.
Additionally, according to Nobel laureate Amartya, the plan neglects primary healthcare by choosing to provide monetary support for treatment at secondary and tertiary stages primarily.
Game-changer or pretender?
The Ayushman Bharat scheme aims to provide monetary compensation and support to that section of the populace that would otherwise struggle to access medical care of any sort.
Through this scheme, the Modi government has created possibilities for increased collaboration between the public and private healthcare industries. It also allows for increasing investment in the secondary and tertiary healthcare sectors.
Despite its noble aim, Ayushman Bharat would be more impactful if the stark differences between public and private healthcare providers was taken into account. Given the condition of public hospitals in most parts of the country, provisions should have been made to improve the infrastructure here, which would have gone a long way in improving healthcare accessibility.
While helpful, the provisions for HCWs and NHPS do not go further in addressing the requirements of national healthcare, nor do they take into account the different public health delivery capacities in each state.
Ayushman Bharat has had a steady start. By all measures, a greater number of people will be able to access its facilities. The key question is whether they are accessing better healthcare or simply being helped to pay medical bills.
Despite the ambitious reach, the Modi government has not addressed healthcare concerns as well as it could have.
With elections looming, the government is keen on promoting Ayushman Bharat as a success story. Yet, the feedback from industry professionals and activists paints a picture of anything but, highlighting a scheme halfheartedly prepared and rushed.
At this stage, Ayushman Bharat helps fewer people than projected, papers over cracks and allows the private sector a greater say in health affairs. Rectifying these gaps can make a true game-changer.
Amartya Chowdhury is currently pursuing a Master’s in International Studies and Diplomacy at SoAS, University of London, and has previously interned at UNAIDS.