Beyond temporary relief
Challenge for Ayushman Bharat will be to spur systemic change in healthcare.
As we move into a new year, I have contradictory feelings about what Ayushman Bharat’s potential.
Bharat Solanki, who turned 20 this year, lives in a slum along the eastern side of the rail tracks in Mumbai’s suburb of Bandra. He crosses everyday to the west of Bandra to work as an apprentice mechanic in a garage.
Last year, around the time Mumbai was in the grip of the Ganesh festival, Bharat started experiencing abdominal pain and weight loss. When several courses of tablets from obliging chemists did not help, he visited a local doctor. The doctor gave painkiller injections, which would reduce the pain temporarily. Later, when I got a chance to study his case papers, it was apparent that over two months Bharat had visited several doctors. This included multiple private clinics and also the public hospital in Bandra where I head the surgery department. He had been treated with symptomatic medicines and his pleas about the lack of response were ignored.
One night in October, Bharat woke up with excruciating pain and vomiting. His family rushed him to a nearby private hospital where after an X ray, they were informed that his intestine had ruptured and he would need urgent life saving surgery. And that the treatment could cost up to Rs 5 lakh and that they would not operate unless a deposit of a lakh of rupees was paid. The family ran around pleading for help. They requested the hospital to give them time to get the money but this was turned down. Eventually, Bharat was brought to our hospitals’ casualty. He was operated within a few hours. His belly was full of foul intestinal contents and there were two holes in his intestine. The abdomen was riddled with small white nodules suggesting tuberculosis. My colleagues tried to salvage the situation. However, just as we thought that the worst was over, we noticed bowel contents seeping out of his surgical wound. One of the devastating effects of TB and malnutrition is on the body’s ability to heal — one of the stitched holes in the bowel had opened out. Bharat needed multi-pronged care for what was now an intestinal fistula. This is a complication that puts huge demands on resources, which include very costly intravenous nutrition support. In India, this often means death for the poor.
Fortunately, Bharat had some things on his side — his youth, a treatable disease and committed family members. He also qualified for the Mahatma Jyotiba Phule Jan Arogya Yojana (previously the Rajiv Gandhi Jeevandayee Arogya Yojana), Maharashtra’s state-sponsored health insurance scheme. This enabled us to procure a specialised apparatus, which sucked out intestinal contents from the wound, costly antibiotics, intravenous TB drugs and nutrition solutions. Three months later, the hole slowly shrunk and finally closed. After three long months in hospital, Bharat was discharged.
Over the last five years, our department has treated a large number of patients with complex surgical problems. My colleagues would tell you that the scheme benefits many of these patients. Prime Minister Narendra Modi’s Ayushman Bharat National Health Protection scheme is a grander pan national version of the scheme that helped Bharat.
Healthcare in India has traditionally relied on “schemes”, which have short-term purchase and enormous emotive impact. However, Ayushman Bharat has shifted the discourse from less emotive but vital areas like budget, infrastructure and system change to the simpler terrain of relief and philanthropy. Like in mass disasters, it’s easier to offer interim relief rather than fixing complex systems. The tertiary care component of Ayushman Bharat is essentially an act of interim relief for major illnesses.
Last week, when I reviewed Bharat, he was looking forward to resuming his work. The kind of questions that troubled me were not on his mind. Why did his neighbourhood doctor give him pain injections when he had TB brewing inside his belly? Why was the diagnosis delayed by months? Why did the private hospital demand such a large sum of money in an emergency? Why is it that a public hospital, which in any case is duty-bound to provide care for all citizens, needs a “scheme” to help procure essential drugs? And what happens to the many poor who don’t qualify under the scheme for lack of appropriate papers? For individuals like Bharat who have been at the receiving end of a healthcare system, the bar of expectation has been set so low that what the system had done for him during the hospitalisation could have only evoked thankfulness.
As we move into a new year, I have contradictory feelings about what Ayushman Bharat’s potential. There is the hope that it will help rescue many of those who are currently caught in the tragic pincer of an inadequate public system and an unaffordable private system. But there is also the apprehension about what the scheme will do to long-term policy. If it reaps electoral benefit, it could strengthen the narrow “scheme”-centred narrative that has distracted from fundamental change. Or it could lead to a quantum jump in people’s expectations from the state and raise the bar on competitive politics. As a response to Ayushman Bharat, Rahul Gandhi was recently quoted as saying that he would implement a scheme like Britain’s National Health Scheme if voted to power. Strange as it sounds coming from a party that allowed a free run for the market in health care under its watch, it’s a leap of imagination. If Ayushman Bharat can feed into solid ideas like publicly-funded universal healthcare we may then be onto something transformative.
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