Pradhan Mantri Jan Arogya Yojana (PMJAY) Diluted old wine in a new bottle? with a Hefty price

Pradhan Mantri Jan Arogya Yojana (PMJAY) Diluted old wine in a new bottle? with a Hefty price

Pradhan Mantri Jan Arogya Yojana (PMJAY)

the largest health insurance initiative in the world

Should we Rejoice that the Modi government has come out with health coverage for the poor?

Is this Diluted old wine in a new bottle with a Hefty price?

Pradhan Mantri Jan Arogya Yojana (PMJAY)/aka/Ayushman Bharat /aka/ National Health Protection Mission (AB-NHPM)

They can’t even makeup their mind on what name to use

After Independence the Indian government promised universal health coverage

India’s steps towards universal health coverage began in the early years after Independence but they faltered because of various factors, including resource constraints. The context has vastly changed since then but the need remains as urgent as it always was.

“There is arguably no aspect of social policy more complex or controversial in today’s world than how a country goes about assuring health for its people. Preventing avoidable physical or mental suffering, ameliorating what is unavoidable and doing so for everyone at a reasonable cost poses a challenge not only in poor developing countries, but also in some countries with the highest per capita incomes in the world.”

Even when the majority of the population was young and the disease burden was mainly infectious diseases the ruling state governments were not able to provide even the percentage of the promised universal health coverage. now that the population is getting older and the disease burden is mainly Is due to Chronic non-communicable diseases It's no wonder that the present BJP government of India has come out with this Pradhan Mantri Jan Arogya Yojana (PMJAY)

This PMJAY Scheme is a mega National Health Protection Scheme (NHPS) for poor people. PMJAY will provide Rs. 5 Lakh health insurance for secondary and tertiary hospitalization. This Ayushman Bharat Yojanawill benefit around 50 crore poor people and will provide them cashless and paperless treatment in hospitals.

How much is 50 crore as a percentage of the total Indian population

Result: 3.69 %

Formula: 50 / 1354 * 100 = 3.69 %

Essentially what  they are saying is,  rest of the 96.31% take care of your health yourself

Even for these 3.69% their medical expenses are more than 5 lakh rupees which is very much likely in many circumstances they have to pay whatever is more than 5 lakhs.

unlike the previous governments( mostly Congress),at least this government is becoming more transparent and sincere, in the sense that they have stopped fooling people by telling them that they have universal health coverage and that everyone can get free health in this independent country.

let us look at what happened so far

Committee Pe committee

“Ups and Downs of UHC in India If an extraterrestrial were to land in India and attempt to understand health provisioning in the country by reading through policy and programme plans, it would be convinced that Indians are a remarkably healthy lot. By the standard criteria, India has had, on paper at least, a universal health system since very soon after Independence. From the Bhore Committee of 1946 on, there have been a series of committees – Sokhey Sub-Committee (1948), Mudaliar Committee (1962), Chaddha Committee (1963), Kartar Singh Committee (1974), Srivastava Committee (1975), Indian Council of Medical Research, Indian Council of Social Science Research (ICMR-ICSSR) Joint Panel (1980) – that have focused on different aspects of the issue, and together resulted in the three tier system of health centres in the public sector for primary, secondary and tertiary care. These have been complemented by two enunciations of the National Health Policy (1983 and 2002), a National Population Policy (2000), the Report of the National Commission on Macroeconomics and Health (2005) and, most recently, the High Level Expert Group (HLEG) on Universal Health Coverage (HLEG 2011)”

Alma Ata – Brave Words and Insufficient Resources: After the Alma Ata Declaration in 1978, the ICMR-ICSSR Joint Panel (1980) stressed the need for a more integrated and comprehensive health system, and called on the government to formulate a national health policy. The result was the National Health Policy that was approved by Parliament in 1983. While the policy paid its respects to the Alma Ata vision of comprehensive preventive and curative care, insufficient investment meant that the programme provided only selective primary healthcare and its actual direction remained largely vertical. There were inadequate resources allocated for the building of human resources, a lack of decentralisation and unregulated expansion of the private sector (Duggal no date). Liberalisation and Privatisation: With economic reforms, the early 1990s saw tax and other incentives being given for setting up private hospitals and clinics, which resulted in a rapid growth of the private health sector. The 1980s had already seen a steady erosion of drug price control in line with the policy climate of liberalisation after the mid-1980s. The number of drugs on the controlled list has fallen from more than 300 at its peak in the 1970s to around 30 at present. The second enunciation of the National Health Policy in 2002 began by acknowledging that 13 of the 17 goals of the previous policy had not been met. It had a number of critiques of the state of the health system – rural-urban disparities in health infrastructure; the limitations of a system centred on vertical programmes; the shortage of medical personnel, especially doctors; and the need to introduce legislation on minimum standards for medical establishments. Recognising that financial constraints had played a key role, the new policy argued for raising government health spending to 2% of gross domestic product (GDP); aligning health goals more realistically to financial and administrative capacities; and increasing the role of the private sector, especially for those who could afford to pay. But while the government adopted the last two approaches by further incentivising the private health sector, including health insurance, and opening up a range of public-private partnerships

the idea of UHC and attempts to move towards it have been with us since the early years after Independence. However, three factors have acted as major constraints to its realisation – insufficient public investment, the absence of political prioritisation or leadership, and a push towards liberalisation and unregulated privatisation. While an increasing focus on the demand side is not bad in itself, there needs to be a much greater emphasis on strengthening the supply side if we are not to face a growing challenge of unmet demand and poor-quality services.

“In India, while some progress has been made towards addressing some of these broader social determinants such as pasteurisation and while there has been a significant decline in family size, the major problems of sanitation, inadequate and unsafe water and serious undernutrition and malnutrition still persist. As a consequence, infectious diseases contributed 38% of the total disease burden in 2005, according to the National Commission on Macroeconomics and Health, and maternal and perinatal ill health 12%.”

In the  past

“ public hospitals, even if of doubtful quality, were available to the poor and largely used by them, especially for inpatient care. In the mid-1980s, there were a number of drugs still left on the controlled list and a thriving market through reverse engineering made competitively priced and reasonably affordable drugs available.”

Post-Reform Policy Shift

What happened after the economic reforms began?

Two policy shifts are important to an understanding of this

– one, a very sharp reduction in the number of drugs on the controlled list, leading to significant increases in drug prices,

two, the introduction of user fees.

More than 70% of health expenses are out-of-pocket, and of these, over 70% are for drugs (HLEG 2011: 96)

Economic gradients of inequality in access to healthcare sharply worsened in the 1990s.

Even public hospitals, which had long been the mainstay of the poor (despite their often poor quality of services), acquired a tilt towards the better off in rural areas by 2004. This was probably a consequence of the two-tier system that emerged during this period.

The poor are therefore financially squeezed and experience difficulty in finding services they can afford, both public and private.

More than 40% of them had to borrow money or sell assets to pay for their care, while more than 35% of them fell below the poverty line because of hospital expenses.

The rural-urban differences in health resources are stark, with 80% of doctors, 75% of dispensaries and 60% of hospitals being in urban areas. The towns and cities have 11.3 qualified physicians per 10,000 population against 1.9 in rural areas.

From the 1980s onwards, trend has been towards establishing mammoth tertiary sector, multi-specialty and super specialty hospitals. They were started initially by professionals who, after having worked in the USA or UK, realised the potential of ‘health care’ as an industry with profitable margins. The success of this experiment was followed by scores of businessmen investing in the health sector.

This led to a  domestic brain drain where the doctors trained in government colleges and the mid-career reputed doctors,were wooed by the corporate hospitals to serve in their hospitals with higher pay packets.Leading  to even worse standards in Public Hospitals.

None of these corporate hospitals, who received land at throwaway prices and tax exemptions, followed the conditions put forth by the government.

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Even as late as  2011 the usual national health song was a song of utopia as seen  by

The HLEG’s definition of UHC( Universal Health Care)

” Ensuring equitable access for all Indian citizens resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable and appropriate, assured quality health services (promotive, preventive, curative and rehabilitative) as well as public health services addressing wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services (HLEG 2011: 3). “

India’s public spending on health ranks among the lowest in the world

So in 2008 Manmohan Singh started

Rashtriya Swasthya Bima Yojana

Government programme

Rashtriya Swasthya Bima Yojana is a government-run health insurance programme for the Indian poor. The scheme aims to provide health insurance coverage to the unrecognised sector workers belonging to the BPL category and their family members shall be beneficiaries under this scheme. Wikipedia

Prime Minister(s): Dr. Manmohan Singh

Launched: 1 April 2008; 10 years ago

Rashtriya Swasthya Bima Yojana

Government programme

Rashtriya Swasthya Bima Yojana is a government-run health insurance programme for the Indian poor. The scheme aims to provide health insurance coverage to the unrecognised sector workers belonging to the BPL category and their family members shall be beneficiaries under this scheme. Wikipedia

Prime Minister(s): Dr. Manmohan Singh

Launched: 1 April 2008; 10 years ago

Other similar but more expensive schemes funded by different state governments in states such as Andhra Pradesh(Arogya shree) [Criticism of  Arogya Shree],Yeshasvini scheme in Karnataka, Kudumbasree in Kerala  and Tamil Nadu are highly popular because they allow poor people who could never have dreamt of it before to access tertiary care at the most expensive private corporate hospitals at no or minimal cost to themselves. The most recent of these is Maharashtra’s Andhra Pradesh-like scheme, the Rajiv Gandhi Jeevandayee Arogya Yojana, to which it has switched from RSBY

Amount of  fraud; and exclusion and inclusion errors can be handled through smart cards, better management and the use of information technology (IT) possibly this is taken care of by the  ADHAR card system.

“ more serious problem is that these schemes are partial to expensive secondary and tertiary care and against more financially viable preventive and primary care (Sen 2011). With no incentives for the latter and little capacity building at the lower levels, effective gatekeeping becomes well nigh impossible. In the medium term, these schemes become unviable very quickly because of the large reservoir of untreated illness; the targeting that works against risk pooling; and because all the incentives are in favour of more and expensive treatment for which the government has to foot a growing bill, as has been the experience of Andhra Pradesh.”

Primary healthcare, including preventive/curative services at the primary level and health promotion targeted towards specific risk factors, should account for 70% of all government healthcare expenditure.

Fraud in Arogyashree

It was found that the hospitals discharged the patients who underwent surgeries earlier than the stipulated time required for recovery. Some of the hospitals collected deposit amount prior to the admission and failed to reimburse the amount, yet collected the bill. Around 22 hospitals were suspended from their service for Aarogyasri patients for faking medical bills (Kakinada News, 2009). However, the government has been keenly tracking and monitoring the network hospitals and around 116 hospitals, who were indulging in malpractices or flouted rules, were delisted

Arogyashree is skewed towards tertiary care( see numbers below ) and for a smaller population at the cost of majority and focused on certain chronic diseases at the cost of communicable diseases.

Dermatology 423

Cardiac and cardiothoracic surgery 129 ,617

Polytrauma 1,241,416

What will be the  effect of Ayushman Bharath?

the leading causes of overall disease burden and mortality are lower respiratory infections, diarrhoeal diseases, low birth weight (malnutrition), tuberculosis, ischemic heart diseases and malaria. Among the main causes of disability are accidents due to fall and fire, depression, epilepsy, schizophrenia and protein energy malnutrition among children. These are the illnesses which hamper the daily life of the poor and have a significant impact on their economic condition.

The focus on tertiary health care to the exclusion of all other forms of medical assistance leads to an inefficient medical care model with a low level of real impact on meeting the needs of healthcare and the health of the population.

Whereas a total of 59,000 surgeries were performed with the `274 crores Aarogyasri budget (mostly in the corporate sector), the Gandhi Hospital could conduct 2.56 lakh operations with a meagre budget of `12 crores (The Hindu, 2008b; The Hindu Business Line, 2008).

The  same 274 crores were given to the  same gandhi hospital about 15 lakh people  would have benefited. the state government spent a quarter of the health budget towards this scheme.

many operation theatres in government facilities remain underutilised due to lack of skilled manpower. Or lack of  simple things like Linen and suture material

“these insurance schemes are turning out to be a ‘cash cow’ for the corporate hospitals”

 Modi govt. has finalized the rate for 1,352 medical inspection and surgeries. The complete list of treatment packages for health insurance scheme will be soon available on the Portal of the Ministry and a new NHPM Portal.

improving nutrition by ensuring food availability (by strengthening the public distribution system) ensuring safe drinking water supply, creating adequate shelter and sanitation facilities, creation of public transport facilities and road connectivity in interior and remote areas to improve access for mobility of patients, strengthening primary education  Will make the Nation Healthier than any “Health Insurance scheme”

Until these needs are addressed for the large number of poor who are living in rural areas, there is little chance for improving their health and getting them out of poverty