COMMENTARY

not been good. The schemes were found

Ayushman Bharat to be inequitable, inefficient, and did not
provide financial protection. The popula-
Hurdles to Implementation One Year On tion covered under the AB–PMJAY overlaps
with, but is not the exact mirror image of,
the population under another insurance-
Shah Alam Khan based scheme of the previous govern-
ment called the Rashtriya Swasthya Bima

T
Taking into consideration the he Ayushman Bharat–Pradhan Yojana (RSBY). The RSBY was targeted at
model of the Ayushman Mantri Jan Arogya Yojana (AB– below poverty line (BPL) families. An
PMJAY) was launched by the Gov- article in the Lancet in 2016 revealed
Bharat–Pradhan Mantri Jan
ernment of India in 2018 (National Health that around 80% of the reimburse-
Arogya Yojana, some valid Authority nd). The AB–PMJAY defines a ments under the RSBY went to private
questions regarding the benefit cover of `5 lakh per family per health set-ups. Besides, the out-of-pocket
operationality and feasibility of year for secondary and tertiary care hos- expenditure for people seeking health-
pitalisation and it is aimed at covering a care was among the highest in India
the scheme are examined.
total of 10 crore families (approximately (Mackintosh et al 2016).
The shortcomings of the scheme 50 crore persons or 40% of the country’s In line with the expected problems of
are brought forth and a solution population based on the socio-economic operationality of the AB–PMJAY, the RSBY
is offered so that the scheme and caste census database) (Bakshi et al too had its share of issues. In a study
2018). The premise of the scheme is to conducted in West Bengal, Bandyopa-
does not stand in contradiction
achieve universal health coverage (UHC) dhyay and Sen (2017) found that the
to various health schemes and to move towards achieving the sus- district-wise performance of the RSBY
of the past. tainable development goals (SDGs) to was extremely variable, particularly in
which India is a signatory. As more and terms of enrolment of BPL families in the
more data becomes available for this scheme. They assign multiple reasons to
ambitious scheme, it becomes necessary the same and, interestingly, these very
to evaluate as to whether the track chosen factors would be at work in the enrol-
by the state for achieving UHC has reached ment of families even for the AB–PMJAY.
anywhere near the assumed end point. They concluded that a combination of
In the first few months of its inception, private hospital providers working togeth-
questions were raised on the operation- er with a private insurance model creat-
ality and the feasibility of the AB–PMJAY ed a monopoly that is failing to control
(Bakshi et al 2018). It is, thus, important costs and monitor for quality or health
to examine whether these valid ques- outcomes. Thus, on the one hand, premi-
tions have been answered or whether ums are increasing rapidly, whilst, on
the government has moved ahead with the other, providers (due to lack of regu-
the scheme without due consideration of lation and oversight) are able to act in
issues of operationality and feasibility. a monopolistic and unethical manner
(Bandyopadhyay and Sen 2017). The
Insurance-based Model social factors which, thus, govern the
The insurance-based model of the AB– functioning of a scheme like the RSBY
PMJAY and the economics involved has would definitely have a bearing on the
been questioned by many (Patnaik 2018). operationality of the AB–PMJAY.
The operational feasibility of the AB–
PMJAY was also questioned both by health Hindrances in Functioning
economists and health activists. It was In a paper analysing the enrolment of
felt at the time of its inception that private hospitals in the health insurance
the scheme was susceptible to issues network in India and its implications
pertaining to hospital empanelment, on the AB–PMJAY, Choudhury and Datta
patient enrolment, and the possibility of (2019) concluded from an extensive analy-
Shah Alam Khan ([email protected]) corrupt practices. sis that the empanelment of private hos-
teaches at the Department of Orthopaedics, All Past experience with insurance-based pitals by insurance companies in India is
India Institute of Medical Sciences, New Delhi.
models of healthcare in this country has relatively low in states with low per capita
Economic & Political Weekly EPW NOVEMBER 30, 2019 vol lIV no 47 13
COMMENTARY

incomes, where a substantial proportion also deprived of the benefits under the regard to both, the accessibility and afford-
of eligible beneficiaries under the AB– RAN scheme since they are now AB–PMJAY ability of healthcare. Invariably, health
PMJAY are concentrated. This appears to cardholders (Saxena 2019). It has been is not a product only of efficient medical
be a serious flaw which has by and large noted that the AB–PMJAY scheme provides services, but is mainly determined by the
remained unanswered by the policy- coverage of medicines post discharge up social and economic conditions of the
makers and needs to be evaluated in de- to 15 days only. A large number of patients, people, including their ability to earn, eat,
tail towards achieving the benefits of the particularly cancer patients, require long- afford decent living conditions, and access
AB–PMJAY. term medication on an outpatient basis. healthcare when in need (Bajpai and
Corruption is the other problem with In the past, such patients could get med- Saraya 2018). The insurance-based model
the operation and functioning of the icines (on an outpatient basis) through of healthcare delivery, like the current
AB–PMJAY. Instances of corruption within the RAN scheme. The need for admission AB–PMJAY, is the distillate of that process of
the AB–PMJAY have already been noticed. as a criterion to avail benefits under the social inequality. If the real commitment
The Union Ministry of Health and Family AB–PMJAY is a big blow to this cohort of is to UHC, then unfortunately only an
Welfare website gives a breakdown of patients. This has not only restricted the insurance-based healthcare delivery model
some of the statistics, which plague the reach of the benefits to the poorest of the is not the answer. We need to learn from
AB–PMJAY on the completion of its first poor, but has also worked against the countries like Thailand. Thailand has
year. According to this information, there principles of the RAN umbrella scheme, achieved UHC in public health at an ex-
are confirmed frauds in 1,200 hospitals which is to give financial benefit to the penditure that is feasible for the Indian
involving the AB–PMJAY. Of these, investi- poor in the treatment of cancer. scenario too (Sundararaman 2018).
gations have been completed in 376 hos- In fact, the AB–PMJAY and RAN should In conclusion, a scheme like the AB–
pitals and first information reports (FIRs) have complemented each other to provide PMJAY is not without its intrinsic flaws and
filed against six hospitals. After the con- an ideal situation of targeting the poorest shortcomings. In the last one year, these
clusion of investigations, a penalty of `1.5 and the deprived of the country. Instead, shortcomings have been visible at multiple
crore has been levied and 97 hospitals the very approach of excluding patients levels. Hence, the operational feasibility of
have been delisted from the scheme. enrolled in the AB–PMJAY from availing the this scheme needs monitoring at multiple
Within the private sector, 71% of the benefits within the RAN umbrella scheme, levels. Marking a finite end point of the
hospitals empanelled have less than 25 along with the exclusion of diseases they scheme is not possible. Clashes and con-
beds and offer non-specialised care (Mani suffer from under the AB–PMJAY, has tradictions with other schemes that have
2019). The document, “Lessons Learned created a dangerous situation for millions historical importance with regard to the
in one year implementation of PM–JAY,” of prospective RAN beneficiaries. This social security net in India (like the RAN) are
available on the AB–PMJAY website, enlists dangerous and dismal situation will sub- deleterious to the intent of an Ayushman
fraud as a challenge that needs to be tack- sequently lead to an increase in out-of- Bharat. A simpler solution to the problem
led for better implementation (National pocket expenditure, adding to disease- would be to incorporate the scheme into
Health Authority 2019). Thus, the potential induced impoverishment. the UHC framework, which of course needs
problems of “profit-motivated” supplier- The cost of consultations in the out- stronger legs to stand in our country.
induced demand by private healthcare patient department, along with the cost of
providers and corrupt practices are medicines and diagnostics is the major References
possible ethical burdens of the scheme contributor to out-of-pocket expenditure Bajpai, V and A Saraya (2018): Health beyond Medicine:
(Gopichandran 2019). in India, which is not covered in the Some Reflections on the Politics and Sociology
of Health in India, Delhi: Aakar Books.
The other problem of implementation AB–PMJAY. This leads to major hardships Bakshi, H, R Sharma and P Kumar (2018): “Ayushman
of the AB–PMJAY which has been high- for large numbers of patients. In a country Bharat Initiative (2018): What We Stand to Gain
or Lose!,” Indian Journal of Community Medicine,
lighted recently in the national media like India, social and geographical factors Vol 43, No 2, pp 63–66.
is its inability to serve the poorest of the compel a significant number of people Bandyopadhyay, S and K Sen (2017): “Challenges of
poor who would previously benefit under (even with serious ailments) to opt for Rashtryia Swasthya Bima Yojana (RSBY) in
West Bengal, India: An Exploratory Study,”
other government schemes, like the outpatient as compared to inpatient treat- International Journal of Health Planning and
Rashtriya Arogya Nidhi (RAN). A recent ment. The lack of coverage of outpatient Management, Vol 33, No 2, pp 294–308.
Choudhury, M and P Datta (2019): “Private Hospitals
report published in the Indian Express costs in the AB–PMJAY is a careless over- in Health Insurance Network in India: A Reflec-
revealed that seriously ill patients—for sight on the part of the policymakers tion for Implementation of Ayushman Bharat,”
NIPFP Working Paper Series, Paper No 254,
example, those suffering from illnesses who designed the scheme. National Institute of Public Financing and Policy,
like end-stage kidney disease, chronic liver New Delhi.
Social Inequities in Accessibility Gopichandran, V (2019): “Ayushman Bharat National
disease, and blood cancers—are being Health Protection Scheme: An Ethical Analysis,”
denied treatment under the AB–PMJAY, In India, the neo-liberal policies of the Asian Bioethics Review, Vol 11, No 1, pp 69–80.
Mackintosh, M, A Channon, A Karan, S Selvaraj,
since these illnesses are not among the 1990s led to major social inequities. This, E Cavagnero and H Zhao (2016): “What Is the
1,350 medical packages defined under in turn, led to inequalities in seeking Private Sector? Understanding Private Provision
in the Systems of Low-income and Middle-
the scheme and, hence, are not covered healthcare. The poor and the underpri- income Countries,” Lancet, Vol 388, No 10044,
by it. These patients, it is reported, are vileged were left at a disadvantage with pp 596–605.

14 NOVEMBER 30, 2019 vol lIV no 47 EPW Economic & Political Weekly
 COMMENTARY
Mani, V (2019): “Patients to Fake Websites: One — (2019): “Lessons Learned in One Year Implemen- Indian Express, 22 September, viewed on 7 No-
Year of Ayushman Bharat Reviewed in Numbers,” tation of PM-JAY 2018–19,” Government of India, vember 2019, https://indianexpress.com/article/
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