Does India’s health system really have the capacity to implement Modi’s mega health scheme?

by Radha Khan & Suvojit Chattopadhyay

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana or PMJAY is one of the most ambitious promises ever made to the people of India. Yet, as with every large promise that is made to the people of India, the state has to be held to even higher standards of accountability.

PMJAY promises financial cover for “almost all secondary care and most of tertiary (health) care procedures” to 10.74 crore families in the country, selected on the basis of the Socio-Economic and Caste Census data. This is the largest publicly funded health insurance scheme in the world. Finance Minister Arun Jaitley during his 2018 Union Budget speech pitched it as an “aspirational” scheme – it increases the sum-insured manifold from Rs 30,000 to Rs 500,000 and it expands the scope of coverage to nearly 40% of the country’s population.

Questions are inevitably raised about different aspects of large schemes. The big questions that have been asked about the PMJAY include: why the funds available are not being spent on strengthening existing government secondary and tertiary facilities, why the private sector is being allowed to profit at the cost of the public sector, why the programme does not cover outpatient-expenses and so on. Another major question is that of its delivery mechanisms.

In 2012-13 when the National Food Security Act was being developed, there was considerable public debate on the capacity of the state to implement it. Economist Arvind Subramanian, before he was appointed Chief Economic Adviser to the Government of India, had written in Business Standard asking how one could expect that a state that was “already enfeebled, leaking and corrupt”  be relied upon to guarantee new rights to its people. Subramanian was not doubting the government’s intent. He was calling for greater efforts to strengthen implementation.

One look at PMJAY and it is evident that here too, implementation capacity is bound to be a critical issue.

Problems of targeting

The PMJAY makes it clear that the proposed health cover is an “entitlement” for “eligible beneficiaries”. The problems with this eligibility criteria are immediately obvious – the process of vetting applicants is cumbersome and has had to be done rapidly to meet deadlines, Aadhaar numbers need to be matched with biometrics, etc. Past experience with social welfare schemes that are constructed upon a “deprivation index” and a master-list have shown how problematic and cumbersome this process of listing of beneficiaries can be – reams of literature is readily available enumerating the myriad problems with the Public Distribution Scheme, and more generally, in the issuance and usage of Below Poverty Line cards.

Such targeting exercises are fraught with difficulty and very likely to not only encourage corruption, but also are prone to elite capture, which will defeat the very purpose of the scheme. The state of healthcare in India is well-documented, and the government recognises that unexpected and catastrophic health expenses is one of the major reasons for families sliding back into poverty. Which is why then, the design of a scheme that has a seemingly arbitrary target of 50 crore beneficiaries strikes us as odd. Will the list of eligible beneficiaries be revised every year? How will we audit whether the registration lists have been verified at the community-level, and not just through a bureaucratic listing exercise? Why not hold gram sabhas in panchayats in order to enable the community to verify and ratify the names? How will PMJAY accommodate economic distress that may change the fortunes of families living on the margins of this arbitrary line to be later made “eligible”? These are not new questions, previous schemes have faced exactly this problem and we see the PMJAY pilot scheme, rolled out in Mewat district, Haryana faced the same problem according to this news report in the Indian Express. It surprises us that despite the learning from the past governments continue to make the same mistakes!

As suggested by civil society activists, a better way perhaps would have been to make the scheme universal – with the option of the middle to upper-classes opting out or  via a process of “self-selecting” as is done in MNREGA or much like the LPG cylinder-subsidy which Prime Minister Modi himself launched and encouraged. A universal scheme has manifold advantages. It is less likely to be captured by the elite at the cost of the most marginal and vulnerable, it is more likely to be efficiently run as the middle classes have a stake in it, and as it is inclusive, it is less likely to be seen by those who are economically better-off as a sop or a handout to the poor.

Supply-side problems will persist

There is a mountain of evidence that shows that the major challenges in the state of public healthcare in India are around out-of-pocket expenses that families incur when accessing services and the informal payments that are made. Moreover, these factors come into play assuming there is a reasonable level of services on offer. In especially in remote rural areas, supply-side issues are rife, starting from a shortage of equipment to dilapidated infrastructure to a shortage of skilled manpower. These will continue to hamper the availability and quality of services.

An important factor on the supply-side is finances. Much has already been written about the financial feasibility of the estimates that the government has made when calculating the burden of premiums that need to be paid to health insurance providers. In the initial years, as the government estimates its financial commitment towards the scheme, there are bound to be problems. Will services be denied if claims exceed budgeted estimates? For instance, in another entitlement-based scheme MNREGA, there have been several reports where work was halted in certain districts when the local administration realised that the demand for work far exceeded the funds available – and this happened in spite of constitutional guarantees from the state to provide 100 days of work per family. How will the government ensure that such a scenario does not play out in PMJAY?

Supply-side and service quality problems can be tackled to a large extent if there are robust grievance redressal mechanisms in place. Even so, a poor person seeking medical care may not be in a position to use these mechanisms for a variety of reasons including the inability to forego work and wages while pursuing redressal. Moreover, the PMJAY outlines measures to be taken only in the case of problems with claims by beneficiaries, providers and other stakeholders, and not problems of eligibility and the very availability of services. These are areas that need to be looked into immediately.

Opportunity to seek accountability

Given the promise and the publicity blitz that has accompanied the roll-out of this scheme, does this give us an opportunity to demand accountability of the state? While poor families have been entitled to free treatment for almost all their medical needs they have often turned away from government hospitals because of the poor quality of service. So far,  people have been unable to hold the government accountable towards its obligations. But we can now try to exert pressure on public and private service providers to live up to the new promise that the government has made on their behalf. Can this form of social accountability lead to tangible improvements on the supply-side?

Those who monitor the government’s development expenditure will have to be vigilant that additional costs of financing PM-JAY does not result in cuts to the primary healthcare budget of the union and state governments. Several researchers and activists have cited examples of how health insurance schemes have often proved to be Trojan horses that governments use to gradually absolve themselves from providing essential public health services. It is now up to the government to prove its critics wrong.

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First published by Scroll

 

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