The Ayushman Bharat scheme, also called the Pradhan Mantri Jan Arogya Yojana (PMJAY), is the National Health Protection Scheme that was launched on September 23, 2018. It is also abbreviated as the AB-NHPM (Ayushman Bharat-National Health Protection Mission). It is the world's largest government-funded scheme (estimated expenditure of Rs 12,000 crore per year, with the Centre contributing 60% and the states the rest 40%), and is targeting more than 50 crore poorest beneficiaries or nearly 10 crore households (8 crore rural and 2 crore urban) and each family would have a cover of Rs 5 lakh per year. It must be noted that 50 crore beneficiaries are almost equal to the population of the entire European Union or combined population of the US, Canada and Mexico.
The Socio-Economic Caste Census of 2011 is the basis of beneficiary identification under the scheme, and it is extended to those families that were availing of the government's earlier scheme, i.e. the Rashtriya Swasthya Bima Yojana (RSBY).
Ayushman Bharat would provide secondary and tertiary healthcare hospitalisation to the beneficiaries across 23 specialities through 1,390 packages, which include treatment/procedures such as cancer surgery, radiation therapy, chemotherapy, cardiac surgery, stents, neurosurgery, spine surgery and specialised tests such as MRI and CT scan, among others, with the flexibility to include more that are not specified as of now. About 16,000 hospitals, of which a little over 50% are private hospitals, have been empanelled so far. It is hoped that about 1 crore poor would be benefited each year (6.85 lakh people got free treatment in the first 100 days of the roll-out of the scheme) as the scheme gathers momentum with increased awareness about the mission. Here, it may also be mentioned that new hospitals would be opened in tier-2 and tier-3 cities, creating new jobs as a result of the scheme.
Having said this, it is now time to analyse the working of AB-NHPM as more than 10 months have elapsed since its launch, and most states and Union Territories have agreed to adopt it. So, what are the limitations and challenges that the scheme faces?
– Empanelled hospitals say that their package rates are inadequate and need to be reviewed and fixed on a scientific basis to make them financially viable;
– In view of the above-mentioned point, it is considered that funding is critical to the success of the scheme. Although the central government has assured additional resources and tapping of other funding avenues, only time will tell to what extent the government can meet its commitment;
– The scheme covers only hospitalisation and not outpatient care, which is to be borne out-of-pocket, but the poor, for whom the scheme is meant, can't afford this. Our statistics show that in India, on average, only about 4% of the total population gets hospitalised and the rest 96% get treated with free services as outpatients, usually near their homes-like the Mohalla Clinics of Delhi. Thus, integrating primary healthcare with secondary and tertiary healthcare under AB-NHPM is necessary. This way, there will be an added advantage that only essential and lesser number of patients would go for hospitalisation, thus reducing pressure on hospitals;
– It is a technology-based programme right from beneficiary identification to transfer of paperless data and claims settlement. Thus, it presents immense difficulties due to inadequate adoption of digital technology in rural, far-flung areas of the country.
Besides the above, the scheme, within 10 months of its implementation, is encountering a big problem as fraudulent practices like fudging of beneficiary data have been noticed by the anti-fraud unit of the National Health Agency (NHA)-the nodal agency for the scheme. In addition, as far as the case of the fake beneficiary cards being issued by the Common Service Centres (CSCs) is concerned, it is said that there are other types of frauds committed by hospitals. These include a single doctor conducting surgeries in four districts on the same day; multiple surgeries on a single day late in the night; patients charged for expensive procedures not conducted on them; and performing hysterectomies. Because of these reasons, the NHA de-empanelled about 250 hospitals, and many CSCs in Agra and Pilibhit districts of Uttar Pradesh have been deactivated. There might be many more such examples from other parts of the country. Although the above-mentioned anti-fraud unit has a fraud detection module with the provision of 94 types of automatic checks in the digital system that would set off alarms if it detects aberrant and unmatching data, hospitals have not desisted from committing such frauds. If they were not aware of such inbuilt checks in the system, the de-empanelling of 250 hospitals would have been a good lesson for all erring hospitals.
Here, it is suggested that we can avoid fraudulent identification of beneficiaries through the use of biometric applications. There is also a need for social audits for safeguarding against frauds. Do we know that about 30% of the total medical expenditure by the government (a huge sum) goes waste due to frauds, corruption and inefficiency in our health system? We can avoid this with strong will and honest intention.
To sum up, if we wish to fulfil our dream of Ayushman Bharat, we must act now and remove all lacunae in the design of the scheme, as suggested above, and eliminate malpractices in implementation by stringent monitoring. Only then can we take pride in calling it a game changer in providing good health to the poor, and thus improving their economic condition and well-being.
(The author is a former ISS and UN consultant. Views are personal)