The Pradhan Mantri Jan Aarogya Yojana (PMJAY) completed 100 days last week. The project is billed as the world’s largest state-funded health scheme. The medical journal, Lancet, has praised the prime minister for prioritising universal healthcare through the PMJAY, which aims to provide cashless treatment to beneficiaries identified through the Central Socio-Economic Caste Census. The scheme covers 1,350 medical conditions ranging from caesarean section to coronary stenting and joint replacement. For each procedure, package rates have been fixed for different levels of hospitals. On paper, the scheme looks good but the ground reality is different.
India ranks as low as 145th among 195 countries in healthcare quality and accessibility, behind even Bangladesh and Sri Lanka. The country spends an abysmal 1.3 per cent of its GDP on health, way less than the global average of 6 per cent. Over 70 per cent of the total healthcare expenditure is accounted for by the private sector. Given the country’s crumbling public healthcare infrastructure, most patients are forced to go to private clinics and hospitals. Health care bills are the single biggest cause of debt in India, with 39 million people being forced into poverty every year. Can the PMJAY change that?
An ambitious project like the PMJAY can succeed only if the government increases its share of expenditure dramatically. Currently, according to a government report, one allopathic government doctor attends to a population of 11,000 — the WHO recommends one doctor for a population of 1,000. The government proposes to augment its share of hospitals by upgrading existing facilities, including converting district hospitals to medical colleges and starting 20 AIIMS. But will that be enough? India falls woefully short of number of hospital beds compared to WHO standards. With over three-fourths of hospital beds being in the government sector, the private sector caters to a small segment of well-off population. So, from where will the beds for treatment under the scheme come?
The government has kept aside only Rs 3,000 crore for the PMJAY this year against the expected outflow of Rs 11,000 crore. How can then one expect adequate delivery of healthcare under PMJAY? Critics also point out the failure of previous government-run health insurance schemes like Rashtriya Swasthya Bima Yojna. The intended beneficiaries of PMJAY are masons, contract workers and farm workers who cannot afford to take off much time for treatment at government or private PMJAY-recognised hospitals. OPD treatment is not covered under the scheme. Another issue, quite unforeseen, is difficulty in locating beneficiaries.
There are additional problems with healthcare delivery in public hospitals under the scheme. Secondary-level hospitals like district hospitals and medical colleges have poor infrastructure, especially the former. The tehsil and district hospitals have inadequate equipment and lack specialist manpower. Not even one of the 20 medical colleges in India offers cardiac bypass surgery. There is also a gross shortage of tertiary care hospitals in the public sector with PGI, AIIMS, SGPGI and NIMHANS being among the few that can be relied upon. However, these public hospitals are functioning beyond their capacity with waiting lists of one or two years for elective surgeries.
The PMJAY seems to have relied heavily on the private sector, realising the inadequacies of the public sector. But can the private sector be depended upon? Most consumers complain of rising costs, lack of transparency and unethical practices in the private sector. Moreover, these hospitals don’t have adequate presence in Tier-2 and Tier-3 cities and there is a trend towards super specialisation in Tier-1 cities. Under the PMJAY, the private hospitals have to get registered and fulfill the minimum requirements. They are also expected to expand their facilities and add hospital beds. Hundred days into the PMJAY, it remains to be seen if private hospitals provide knee replacement at Rs 80,000 (current charges Rs 3.5 lakh) bypass surgery at Rs 1.7 lakh (against Rs 4 lakh).
The PMJAY has created an excellent opportunity for the country to improve its health care. While the contribution of the private sector will be the key to its success, it’s the will and zeal of the government to implement it that will make or break the scheme.
This article first appeared in the January 12, 2019, print edition under the title ‘One hundred days later’