Recent media reports, including ones in this newspaper, have raised concerns that Ayushman Bharat promotes secondary and tertiary care at the cost of primary care. These reports attribute these concerns to Amartaya Sen’s recent comments on the scheme, which may have been taken out of context. Sen’s views on the need to strengthen primary care might have been wrongly construed as his disapproval of Ayushman Bharat. Other reports suggest that the scheme, at best, targets a narrow set of healthcare issues and, at worst, benefits only a few rich individuals.
Sen’s reported comments and other concerns can be deconstructed as: One, Ayushman Bharat as a solution is not consistent with the problem — in other words, the scheme is a giant leap in the wrong direction. Two, primary healthcare has been historically neglected and the resources spent on Ayushman Bharat can instead be spent on strengthening primary healthcare. Ayushman Bharat will benefit only a few rich individuals, the doubters claim.
There seems to be a perception that all health needs in India relate only to primary care and there is no need to expand support for tertiary care. There is also a perception that Ayushman Bharat is taking away resources from primary care and benefiting big private hospitals. A careful analysis shows that both these perceptions are wrong.
Even if we do our best to promote good health, there will still be a critical need for tertiary care and secondary care. First, even with the best prevention programmes, we will still have a significant prevalence of non-communicable diseases. The countries with the best preventive systems have strong provisions for secondary and tertiary care. Moreover, with the aging of population due to increase in life-expectancy, diseases related to old age will increase — even among the poor. Third, a strong primary healthcare system requires an equally strong secondary and tertiary healthcare system. Screening for cancers, for example, has limited utility if there is no system to treat the disease. Secondary and tertiary care in the country is largely provided by private sector. These services have largely been, hitherto, inaccessible to the poor. Ayushman Bharat has changed that.
Ayushman Bharat has two legs. The Pradhan Mantri Jan Arogya Yojana (PMJAY), covers more than 50 crore people in the country — the poorest — against serious illnesses. It has an equally important and equally ambitious leg to strengthen primary healthcare — the scheme seeks to upgrade more than 1.5 lakh health facilities to health and wellness Centres (HWC). The perception that Ayushman Bharat does not support primary healthcare might be due to greater visibility of PMJAY in the media as compared to the other leg. An ailing person treated successfully under PMJAY is more visible, emotionally more appealing and makes for a better “news”, as compared to the screening of millions of people for cancer, for example. However, actually, the scheme’s two legs complement each other.
Could the money spent on Ayushman Bharat be better spent on strengthening primary healthcare? Ayushman Bharat is a very recent initiative. The chronic neglect of primary healthcare in the country cannot be attributed to it. The resources spent on the PMJAY component of Ayushman Bharat are still a very small proportion of the entire health budget. A major portion of the health budget is spent on primary care and secondary care, almost entirely focused on public sector supply of the healthcare services.
There is no trade-off between primary care and curative care; the policy challenge is to strengthen both. Ayushman Bharat does exactly that with its two legs. In the medium-term, we need to expand the public resources for the health sector. The 2017 Health Policy clearly commits to increasing the health sector allocation to 2.5 per cent of the GDP — for decades, the health sector’s budget has hovered at around 1 per cent of the GDP. We have recently seen very high level political commitment for the health sector — perhaps for the first time in recent decades. We have also seen an increased allocation for the sector. If this trend continues, we should be able to provide much needed tertiary care for the poor without compromising the support for primary healthcare.
The assertion that Ayushman Bharat will benefit only few rich individuals is highly misleading. In fact, the initiative will benefit the poorest in the country. The concern that some private insurance companies will receive a windfall gain is also misplaced. States have freedom to choose the implementation model; in fact, most states, including all the large ones (UP, Bihar, MP, AP) have decided to use a trust model where the government directly purchases healthcare services from the hospitals without using any insurance company. Of the states that are using the insurance model most have resorted to public sector insurance companies. Finally, the scheme has a “claw-back” clause in its model contract, which limits the margin of the insurance companies to only 15 per cent — they will have to return the government any extra margin. This margin includes administrative expenses and therefore the potential profit is much less than 15 per cent, while the loss for the company could be quite high.
The scheme’s design ensures that private sector hospitals do not unduly receive a large proportion of financial resources. The payment for services is based on fixed package rate for each procedure, which is largely based on the marginal cost. The scheme also has strong features for preventing, mitigating and deterring fraud and abuse.
The momentum gained by the scheme in a short period since its launch testifies to the huge unmet need for curative care in the country. If the momentum continues, it will dramatically change the face of the country’s health sector in the country — for the better. It will prove to be a giant leap towards Universal Health Coverage.
This article first appeared in the print edition on March 21, 2019, under the title ‘A misunderstood scheme’. The writer is CEO Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.