Long Road for an Ayushman Bharat

Ayushman Bharat, the flagship scheme of the government of India completes two years since its launch on this day in 2018. The scheme aimed at meeting the objectives of universal health coverage (UHC) in India is designed based on the recommendations of the National Health Policy 2017. The scheme, which aims for a comprehensive health care delivery has two major components; Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY). While HWCs aim to cater to a severe shortage of primary care centres, the PM-JAY assures a health coverage of up to rupees five lakhs to the bottom 40 per cent of country's population (approximately 10.74 crore households or little over 50 crore people). PMJAY is the largest health assurance scheme globally. It provides a cashless cover for treatment of approximately 1300 predetermined health conditions to the eligible population.

Prior to the launch of PMJAY, the health assurance schemes were rather small as each state aimed to provide a scheme based on its financing capacity and budget priorities. Some states excelled, while others lagged. Similarly, even the Rashtriya Swastha Bima Yojana (RSBY), which preceded PMJAY, was limited in its scope and coverage. The PMJAY which aims to revolutionize health care access and financing in the country has subsumed health assurance schemes provided by the State governments. Except for Delhi, Odisha, Telangana and West Bengal, all other States/Union Territories are implementing the scheme. As per the agreement, the cost of financing PMJAY will be borne by Centre and States in 60:40 ratio with the exception being the North Eastern States and the three Himalayan States where the Centre will share 90 per cent of the cost. In Union Territories without a legislature, the Centre may provide up to 100 per cent.

Public health is a state subject in India and with PMJAY, the Central government aims to play a dominant role. The question thus arises on its ability to raise financing to cater to its lion's share in the implementation and success of the scheme. A look at the budget allocations to PMJAY reveals a disturbing story. In the first year of its launch, the government of India allocated a paltry Rs 2,000 crore. In its first full year of implementation (FY2019-20), the government raised the corpus allotted to the scheme to Rs 6,400 crore. However, as per the revised budget, the provision for PMJAY was cut by a whopping 50 per cent to Rs 3,200 crore. Nevertheless, in the budget for the current year (FY2020-21), the budgeted allotment was raised to Rs 6,400 crore. With a twin blow of pandemic induced lockdown and limited medical facilities along with weakening economic scenario, it remains to be seen how much the actual outgo is in the current year.

According to the dashboard on PMJAY website, as of today, the total empanelled hospitals are 22796 whereas a total of 7.82 crore e-cards are generated. This indicates that till date approximately only 15 per cent of the eligible population has been enrolled in the scheme. A 15 per cent registration in two years will be a decent performance if the scheme was being built from scratch but, since PMJAY subsumes existing states’ health insurance schemes as well as the beneficiaries of RSBY, the progress appears rather muted. The total number of hospitalizations under the scheme has reached approximately 1.09 crore whereas the claims paid are 65.5 lakhs or 60 per cent of the admitted population. Of the total claims, 49.8 per cent were for surgical cases whereas 45.3 per cent were for medical reasons. The remaining were unspecified. The total value of the number of claims paid is Rs 7,564 crore with an average claim value of Rs 11,500 per claim. As per the data from the 75^th round of NSSO survey, the average cost of hospitalization in India in 2018 was a Rs. 20,135, almost twice the claims paid under PMJAY.

Looking at the medical conditions, which the scheme covers, this amount is a rather small hinting at limited financing to the scheme. A Centre for Policy Research (CPR) study also observed that there were severe delays in the release of funds for PMJAY and as of November 2019, only 16 per cent of the allotted funds to the scheme in that year was released. The study also notes that there have been beneficiary validation and low availability of empanelled hospitals in some states, which is leading to a gap in the demand for services and there actual utilisation. Limited funding along with delays in releasing funds will only give rise to the consumption of health services financed by the households themselves, thus leading to a high incidence of out of pocket expenses (OOPE), the very issue PMJAY aims to address. 

For India to become truly Ayushman, it not only needs to substantially increase the budget for health care but also build an adequate medical infrastructure to support its large population and their growing health care needs. Let us wish glory and success to Ayushman Bharat and hope that it ages gracefully.