The Central government’s publicly-funded health insurance program Pradhan Mantri Jan Arogya Yojana (PMJAY) saw a heavy boost of 166% that is from Rs 2,400 crore which was estimated in 2018-19 to Rs 6,400 crore in the union budget 2019-20. This scheme claims to provide cashless treatment to the poor cardholders in the public and empanelled private hospitals; the cost of the treatment is later claimed and recovered by the service provider from the government. Prime Minister Narendra Modi has termed this scheme as a “game-changer initiative to serve the poor” . On the other hand, the total outlay on National Health Mission (NHM), which is the main vehicle of strengthening public health services and promoting better health outcomes saw an increase of Rs 2,312 crore, that is merely an increase of 7.5%. Considering the inflation rate of 8.65% in May 2019 with respect to the same month last year, this increase in the allocation of NHM is hardly of any significance. In fact, the total budgetary increase of around 8% for the health department except for the allocation to PMJAY barely covers inflation.
This steeply biased increase in allocations to the PMJAY which is under the larger umbrella of Ayushman Bharat indicates that the government is banking fully on this scheme to convince the people regarding the efforts it is putting to improve the dismal healthcare scenario. However, the problem lies in the dismal state of the healthcare infrastructure which does not fall under the scope of this scheme. The Urban portions of India which constitutes of only about 30% of the population are served by about 80% of doctors and 75% of dispensaries, leaving the rest in dire need of basic health facilities. There are only 0.9 hospital beds per 1,000 population, whereas the figure is 6.5 per 1,000 population for developed countries. In India, 6 doctors have to serve about 10,000 people, while the figure is about 30 for developed countries. Even in 2015, 15% of the children did not have access to basic vaccines (World Bank figures) .
Lack of government health services results in the dependence of patients including the ones who are availing this scheme on the private sector. As our previous article on Ayushman Bharat  which provides more information on this scheme points out, private medical sector remains the primary source of healthcare for 70% of the urban households and 63% of the rural households. Thus, the major focus of the government on the Ayushman Bharat scheme along with a consistent lack of attention to improve the public healthcare infrastructure will aggravate the transfer of public funds to private hands. On top of this, a large number of these private hospitals are tainted with malpractices. Even within this short period of execution of Ayushman Bharat, last month, cases have been reported where “ghost patients” have been referred to private hospitals by government doctors. The money meant for the treatment of these non-existent patients would then be pocketed by the nexus of government doctors and the private hospitals . Eleven private hospitals in Uttarakhand have been accused of irregularities that have been detected in their operations, particularly while utilizing funds under the Ayushman Bharat .
A study of the tender documents of the Ayushman Bharat revealed that de-empanelling or debarring a private hospital from the scheme, even in case of serious corruption, has been made extremely difficult. The scheme has also provisioned auto-empanelment of the private hospitals which were under the preceding healthcare scheme Rashtriya Swasthya Bima Yojana. The poor infrastructure of the previously empanelled hospitals is widely known. Experts indicate that the automatic inclusion of such hospitals without field visit would prove disastrous. Moreover, there are reports that the Third Party Administrators (TPAs) to ease the process of implementation of the scheme have mostly been appointed by the Modi government from persons, companies, etc close to the BJP-RSS. The Modi government has roped in a German technical assistance agency – GIZ as a consultant for Ayushman Bharat despite knowing it’s tainted past. Further, the “Trust Model” of the scheme which does not deny or verify any claims provides ample scope for the private player to exploit the public funds with dubious or inflated claims . Thus, it seems that rather than keeping the benefit of the poor in mind as claimed by PM Modi, this scheme is designed prioritizing exuberant profit that the private hospitals and agencies can extract from public funds.
Further, all the services in this scheme provision only secondary and tertiary healthcare. Going by the latest Economic Survey 2018-19, tabled in the Parliament on July 4, 2019, primary healthcare in rural areas, whose importance and the role it plays to slash healthcare expenses for the poor has been pointed out in our previous article , are in a grave situation. 60% of primary health centers (PHCs) in India have only one doctor while about 5% have none. Gujarat, emerged the worst performer, with more than 90% PHCs having just one doctor. The state was followed by Kerala and Karnataka (80% each) and Rajasthan, UP, and Bihar (70% each). More than 10% PHCs in Jharkhand and over 20% in Chhattisgarh function without doctors, the Survey stated. There is no effort by the government to improve the situation.
With the public health expenditure of only a little over 1% of the GDP, India ranks 145th among 195 countries in terms of quality and accessibility of healthcare, behind its neighbours like China, Bangladesh, Sri Lanka and Bhutan, according to a Lancet study . The criticism goes beyond numbers as Lancet goes on to comment that “Newborn in war-ravaged Somalia and Afghanistan has a better chance of survival than in India”.
All these facts indicate that on one hand the gloomy budgetary allocations for health infrastructure will weaken the public healthcare system, facilitating the private players. On the other hand, the schemes like Ayushman Bharat – PMJAY which siphons public funds to private hands will play a supportive role for the private healthcare corporations, rather than benefitting the people. Thus, Ayushman Bharat is a carefully designed policy of the Modi government to facilitate private healthcare corporations to expand their market, masquerading as a “game-changer initiative to serve the poor”.