Autumn Number 2019

Can Ayushman Bharat make a Difference?

Smarajit Jana

In the backdrop of crumbling public health care delivery system, steered by the ruthless corporatisation of secondary and tertiary health care services in the country, the Prime Minister of India declared a 'grand' health development program in the month of September 2018. This is coined as Ayushman Bharat Yojana (ABY) or Pradhan Mantri Jan Arogya Yojana (PMJAY). Apparently it looks like a centrally sponsored programme, however implementation is primarily depends on the interest and whims of various state governments. The vision and approach of the scheme is nonetheless big which encompasses primary as well as secondary and tertiary health care services. At the outset one may expect that the implementation of PMJAY could bring substantial benefit to the masses through improving the ongoing healthcare delivery system in the country.

Under PMJAY there are two major components namely National health protection scheme [NHPS] and the second one is the development of Health and wellness centre (HWC).

The National health protection scheme (NHPS) is a medical insurance scheme like many other ongoing public and private health insurance programme in the country. As per the initial communication NHPS will subsume all existing ongoing health insurance schemes of the National Govt namely Rashtriya Swasthya Bima Yojana (RSBY) developed for the poor and informal sector workers and their families, Central Government Health Scheme (CGHS) which is meant for the Central Government employees, and Employees State Health Insurance Schemes (ESIS) designed primarily for the industrial workers and their family members [which was further expanded to incorporate other occupational groups]. NHPS as promised would cover more than ten crores of under privileged and poor families in the country who for all obvious reasons could hardly access secondary and tertiary healthcare services. Benefits of the NHPS scheme are portable across the country. The eligibility criteria are based on the SECC (Socio-Economic Caste Census) data base. For urban areas eleven occupational groups are entitled for the scheme which includes beggar, rag picker, domestic worker, construction worker among others. In rural areas all SC/ST households, female headed families are among the beneficiaries. As part of the management strategy the central Government has established National health protection mission council at the country level followed by each and every state would constitute their state health survey (SHA) to initiate the process of implementation. Insured families don't have to pay anything from their pocket. The payment of premium will be shared between central and state governments. Central Government would share 60% of the cost and the rest 40% would be the states' contribution. For union territories Central Government will share 100% of the cost of NHPS.

Through NHPS Medicare services could be made available to all registered family members who could choose services from the public health care institutions or from the empanelled private hospitals & nursing homes. Registered family members are entitled to access any kind of indoor medical or surgical treatment. As planned it would be cashless to the family members with an upper limit of Rupees five lacs per year per family. The said insurance scheme (NHPS) though promised to pay cost for pre and post care services for the hospitalised patients; it does not support OPD (outpatient) services which are more frequently needed. One of the objectives of NHPS is to address high rate of out of pocket expenditure by the family members to access Medicare services in India which stands around 78% of total expenditure. There is an international hue and cry and WHO seems very concerned about this issue. When one compares out of pocket expenditure with other developing or developed countries India stands apart. A British citizen spends less than 18% of health care expenditure from their pocket. Even in other Asian countries like Srilanka (16%) or Thailand (24%) spend much less in comparison to what an Indian citizen spends to avail health care services out of pocket. As a result of which each and every year as per the study roughly five crores of household moves below the poverty line due to 'catastrophic health care expenditure' (When the health care expenditure goes above 40% of total household expenditure). The same document of Ayushman Bharat elaborated it further quoting the National sample survey (NSSO) estimates which showed that since 2004 to 2014, the situation has further worsened. There has been a 10% increase in households who suffered from the catastrophic health care expenditures during this decade. As a result of which 12th five year plan kept reduction of out of pocket expenditure as one the eight health outcome indicator. There is no secret behind the cause of this kind of pauperisation among the households which is ever-increasing in India. There is a confession in the document of Ayushman Bharat as it goes on explaining. "This could be attributed to the fact that private sector remains the major provider of health care services in the country which caters to over 75% and 62%, of outpatient and inpatient care respectively''. As per the study report of NSSO on an average an individual in the country spends 78% of Medicare services out of pocket. Again out of this expenditure 75% goes to buy outdoor services which include payment to consultants, buying of medicine and payment for laboratory investigations. If NHPS functions effectively one can expect that it would be able to put a brake through curtailing out of pocket expenditure for families who require indoor services. However as mentioned NHPS does not support outdoor services to the insured family members. As a result of which some of the families shall find any other alternatives but to take loans with a high rate of interest primarily from the money lenders to pay for costly investigations and alike. They will run the risk of catastrophic health care expenditure which can't be addressed by NHPS.

The other problematic issue is the Govt's intention to subsume all other existing insurance schemes which are in vogue. Ongoing health insurance schemes run or managed by the Govt are for different categories of citizens and occupational groups. How the existing insurance scheme meant for the employees of the Central Government (CGHS) who are mostly 'white colour' workers could be clubbed under the Ayushman Bharat which is designed for the poor and economically disadvantaged population in the country?

It is outrageous to bring the beneficiaries of the Employees state insurance scheme (ESI) under NHPS which is one of the best and the most comprehensive health and social protection scheme developed primarily for the 'blue colour' workers as early as 1948. Ministry has already taken a decision to weaken the ESIS through making it optional to the Employers. So at the end who is going to be benefited through Ayushman Bharat and at whose cost is a big question? It is certainly the business community who will be more than happy as they will be spared to ensure health and social protection services to its employees. Is it just the ignorance on the part of the Ministry about the provision of ESI scheme or is a part of a grand design to pull out all existing health and social protection services meant for different categories of labourers in the country and just to provide fillip to business communities? Moreover both these insurance schemes provide outdoor Medicare services to the insured family members which is one of the most important and critical element of health care services and mostly needed for family members. If it is done away through bringing these schemes under the NHPS families who are insured under the CGHS and the ESIS would be the worst looser. Secondly ESI scheme not only protect and promote health of the employees; in addition to that it provides sickness benefit [paid leave to the employee who is absent due to illness].Through ESIS insured members are entitled to claim disability benefit out of work related injuries or from occupational illnesses. There is provision for dependant's benefit to the diseased employee's closest kin including funeral benefit as well. Through one stroke of NHPS all these services will be made history to working masses in the country. However subsuming RSBY under this scheme may be a good idea, as insured members under RSBY would be able to access cashless. Medicare services to the tune of 5 Lacs which is just Rs 30000 at this moment.

Keeping in view the present state of public health care delivery system in the country it is more likely that family members would prefer to access Medicare services from the empanelled private hospitals leaving the public hospitals which are struggling to deliver questionable quality of services. Under PMJAY there is no commitment on the part of the central govt to improve and upgrade existing public health care delivery system and there is no budgetary allocation for district and rural hospitals including state run medical colleges. To improve the quality of services delivered through these public health care institutions calls for infusion of substantial sum of money to modernise those hospitals so as to make those capable of providing adequate and quality of Medicare services. Even though Govt has decided to open seventy five new medical colleges by 2021 ostensibly to produce additional fifteen thousand medical doctors per year. All these medical colleges would be linked to district hospitals. However the Ministry is mum about rest of the district and rural hospitals. As health is a state subject one may consider that the onus shall go to the state Govt? The fact is that most of these state Govts are not committed to do that neither they have adequate recourses to infuse huge sum of money to improve and upgrade physical infrastructure of these hospitals. In addition to that there is an urgent need to procure various diagnostic and treatment related tools, equipments etc. How to attract and recruit medical doctors followed by their placement in these hospitals remained a formidable challenge. Under these circumstances it does not require much intelligence to draw the conclusion that the very scheme would 'indirectly provide fillip to private health care sector and at the cost of further worsening the public health care delivery system in the country

The Health protection scheme which was launched in September 2018 till date only fourteen states have endorsed the scheme. Out of which some states have started a very slow process of implementation? Government of West Bengal among others has rejected the scheme based on their own reasons. Till May 2019 out of 10.74 crores of eligible families only 41632 got registered in all these fourteen states. It is too early to comment on how the process of expansion would unfold and what could be the actual coverage in coming years. One has to wait longer to know to what extent Medicare services are going to be utilised by the registered beneficiaries and what could be the level of performance of the said scheme. The ongoing experience with RSBY is not encouraging as only a miniscule proportion of insured persons has availed services. Whether a similar health insurance scheme will be effective and useful and whether insured families would be capable of claiming requisite services depends on many other social, managerial and structural factors in addition to the norms and practices of the scheme which are likely to be identified in coming years.

The other major component of the PMJAY is to transform the existing Primary and sub centres into HWC. So far all these existing primary and sub centres for various reasons could manage to provide services only to a minuscule proportion of the population. All these centres are incapable of providing adequate and quality health care services. Major challenges include non-availability of qualified medical doctors; irregular and inadequate supplies of essential commodities, poor infrastructure, and lack of monitoring and so on so forth. Sub-centres are designed to cater three to four thousand people in the rural settings. Most of these centres are operating in namesake and providing very little services. The physical infrastructures of these centres are in a shambles. This sorry state of affairs is primarily linked to poor political commitment with inadequate supply of human and financial resources. Secondly people in general have lost its faith and interest in the type and quality of services delivered through these centres. In addition to that there is a strong 'pull factor' from the private healthcare sector. The budgetary allocation both from state and from the central Government is abysmally low. In the introductory note of the operational guideline of Ayushman Bharat has also accepted the truths that service utilisation from these health care centres are extremely poor. Study findings showed that only 11.5% of the households in rural areas and about 4% in urban areas avail outdoor services from sub-centres. Keeping all these challenges in mind how different would be the implementation strategies of PMAJ and what sort of value addition would be made by these HWCs is not clear. Is it going to be the old wine in the new bottle or something different? The stated objective of HWC is to expand the existing package of health care services through inclusion of numbers of curative and palliative service elements. As per the design, all HWC's would incorporate twelve major categories of health care services in addition to mother and child health related services. It includes management of all major communicable diseases, emergency medical services for trauma and burns, prevention and screening of non-communicable diseases, mental health, eye and ENT and oral health care services among others. There would be provision of services for elderly including palliative health care services.

As planned a new 'health cadre' would be developed, named as community health officer or CHO. She/he could be a graduate in community health or a Nurse or an Ayurveda practitioner trained and certified from designated Institutes ostensibly to bolster public health care activities. However critics are raising concern whether Government's ulterior motive is to position them as 'doctor' as most of these centres are run without qualified medical doctors at present. This concern appears to be true. As per the new legislation passed in the parliament [ June 2019] named as National Medical Commission (NMC) replacing the age old Medical Council Act has made the provision for CHO to prescribe allopathic medicine. In the past it could be observed that numbers of state Govts brought out strategies to ensure recruitment and retention of medical doctors in health centres through compulsory rural posting for doctors, making it mandatory to serve rural centres to get registered in post graduate courses, pushed medical students to sign bonds to serve village posts while getting admitted in medical school and so on so forth but none of these strategies made any significant impact. There are many and multiple reasons behind the non availability of medical doctors in rural health centres. Qualified medical doctors are not finding any interest to serve at the health centres in villages or in semi urban settings with little or no facilities for bring up their kids and family members. Moreover remuneration paid to doctors is also not very attractive to them. On the other hand in India there are sort supply of medical doctors and nursing professionals specifically. As per the WHO guideline there showed be one medical doctor per thousand populations which in case of India is one per 1456 population. Barring few states, in all other states it is less than what it should be. Secondly doctors are mostly concentrated in urban areas, leaving vast areas uncovered in the rural India.

Though the Ministry of health has came up with operation guideline for HWC's which appears quite elaborate but the said document is silent about the bigger challenge i.e. how to ensure posting of medical doctors in these centres. Perhaps this might be one of the reasons why govt has mooted the idea to start a bridge course for the practitioners of traditional systems of medicine who would be transformed as the practitioners of modern medicine through providing some amount of training to them on modern medicine.

The progress of HWC is far from encouraging. Till the end of May 2019 out of approved 15,293 sub-centres [the total target is one lac fifty thousand] 7103 HWC have been made operational. As per the report 8940 PHC has been transformed into HWC which is little dubious. There were one lac fifty three thousand sub-centres and more than twenty five thousand primary health centres in the country [2015]. Following declaration of Sustainable Development Goal [SDG] National govt took initiative to upgrade PHCs to Community Health Centres [CHC] incorporating similar curative health care services which are articulated under HWCs and by 2014 around 5363 community health centres got established in different parts of the country, It is more likely that CHCs in operation are renamed as HWC with little addition of health promotional services like Yoga. Whether all health care components mentioned in the plan are in operation in all these HWCs is not known neither anybody knows the quality of services delivered through these centres. There are eight major domains under HWC's which include universal screening for non-communicable diseases, supply of all essential medicine numbering ninety plus. There are provisions for eighteen diagnostic services in addition to ensuring community outreach. As envisaged all HWC centres showed have sufficient space not just for the outpatient care, but space for dispensing medicines, space for diagnostics services, in addition to that there will be space for Yoga and exercises for the community members. Enough health promotional materials will be displayed at the centres to inform people how to promote health and to prevent illnesses. There is a provision under the charter of the Ayushman Bharat to constitute well equipped mobile medical units to serve people living in difficult terrains and remote areas. There is a well throughout plan to implement 'referral' mechanism so that it could reduce congestion at the district hospitals and on speciality and super speciality hospitals. However these are not necessarily new thoughts. It was conceived as part of the health improvement strategies followed by the declaration of SDGs. As part of the implementation plan HWC's includes provision for tele-consultation for which a strong IT platform would be instituted in all these centres.

However, to make 1.5 Lac HWCs operational Rs. 1200 crore has been allocated which is too little to make any change to happen. It is not the fact that Ministry of health does not know this, in fact they have mentioned in the document that private institutions and philanthropic organisations would be roped in to develop HWC's and will be requested them to adopt these centres. Perhaps the underlying philosophy is not just to outsource HWC but in turn to 'privatize' the primary health care systems in the country.

The other important push which is coming from the Ayushman Bharat is to mainstream Ayush which consists of six age-old traditional health care system which includes Ayurveda, Unani, Sidha Yoga, Homeopathy and Naturo-pathy. Each of these systems of medicine has its own roots and philosophy. At present Ayurveda and homoeopathy outdoor services are part of existing PHCs in most of the states in India. However to give more credence to these systems of medicine central Government has created a separate Ministry called Ministry of Ayush. A set of acts and rules has already been created to systematise service delivery mechanism of Ayush which includes indoor services too, in addition to promote safer use of these medicines, guidelines for registration of Naturopathy practitioners and accreditation of Institutions are in place. The National Government has passed a bill called Indian Medicine and Homeopathy Pharmacy Central Council Bill 2016. In the recent past Government has included SOWA-RIGPA, a Tibetan system of medicine under Ayush.

Apparently, all these steps undertaken by the Government to mainstream Ayush sound positive. However, the dismal budgetary allocation over the years speaks a different story. As per the Government's statistics during 11th plan (2007-2012) the revised estimated budget was Rs 3093 crores, during the 12th plan (2012-2017) there was no increase rather fall in revised estimated budget (2788.78 crore).This budgeted sum of money is meant for the development of existing hospitals and dispensaries, to ensure quality control of drugs, development of institutions, in addition to support numbers of central sector schemes. There are more than three thousands hospitals under Ayush, most of which are under Ayurveda followed by Unani, Siddha and Homeopathy, there are around five hundred undergraduate colleges and more than hundred PG colleges under Ayush. There are nine thousands manufacturing units mostly in Ayurveda. Total registered practitioners under all these systems of medicine are around eight lacs The budgeted amount of money appears too small to create any significant impact. It is also not very clear whether Government is truly committed to reposition Ayush through upgrading traditional systems of medicine following scientific scrutiny and research. It requires long term vision and strategies to lay down processes and systems to carry out research and development activities, which also require substantive sum of money. Perhaps Govt is more inclined to provide jobs to a section of practitioners of Ayurveda through their placement as community health officer in HWCS who under the section 32 of the NMC are entitled to prescribe allopathic medicine which will certainly make Pharma houses more than happy. It is projected that the volume of pharmaceutical market which is around 1.23 lakh crore (2018) in the country would be expanded by 50% to 100% within a short span of time.

However, this is not going to help growth and development of Ayush rather the approach would destabilize the traditional systems of medicine and its practice. Secondly the poor countrymen will find no other alternative but to consume '2nd grade' services from these CHOS posted in HWCs. It would institutionalise the notion and the ongoing practices that the scientific and developed from of Medicare services are meant for the economically solvent citizens of the country who would buy health care services from the market leaving the underprivileged community member at the mercy of CHO and to accept compromised quality of health care services.

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Frontier
Autumn Number 2019
Vol. 52, No. 13 - 16, Sep 29 - October 26, 2019