Ayushman Bharat: A Pandemic Report Card

By Arunima Rajan

Reams have been written about the relevance of schemes like PMJAY for the bottom of the pyra-mid. But how did it perform during 2020?

In a tete-a-tete with Arunima Rajan, Oommen C Kurian talks about what needs to be done to strengthen the Ayushman Bharat scheme and how people utilised it during the COVID-19 pandemic.

Kurian leads the Observer Research Foundation (ORF) 's health initiative. ORF is a prominent public policy think tank based in New Delhi. Trained in economics and social medicine, he is a member of the India Task Force of the Lancet COVID-19 Commission.

How did PMJAY perform during the pandemic? There were reports that claims fell drasti-cally during the lockdown.

The pandemic's initial days had seen a significant reduction in the number of claims, partly because of the disruption causing many private sector hospitals to go offline. Due to the lockdown, there was a considerable decline – around 70%- in the number of hospitalisations across the country. However, some states such as Punjab, Manipur, Uttarakhand, and Sikkim observed only minor declines. On the other hand, Assam, Arunachal Pradesh and Maharashtra showed more than 80% decline in utilisation.

How can we address this issue?

There have been steps taken to address the issue including a fast-tracked empanelment drive, and utilisation levels are reportedly close to pre-lockdown levels. The initial panic triggered by the pandemic had made it difficult for many private hospitals to function due to staff shortages, and patients were delaying care for non-COVID-19 conditions, worried about contracting the virus at the hospitals. As things are getting better slowly in most states, the scheme's functioning is improving as well.

Should the government earmark more funds for Ayushman Bharat? Or instead of playing the role of a payer, should they start playing the role of a provider?

Ayushman Bharat is a misunderstood initiative. It is widely seen as an insurance scheme. It is, on the other hand, an earnest attempt to transcend the payer-provider divide. Its Health and Wellness Centre (HWC) component intends to create new, improved public healthcare infrastructure across the country. Through PMJAY, it leverages the existing secondary and tertiary healthcare infrastructure to provide free care to the population's relatively poorer sections. We need to note that the scheme is inherently biased towards the public hospitals, since government budgets already support them, and they also get additional revenue through claims under PMJAY. Overall, higher allocation to Ayushman Bharat will not necessarily mean that the government's role as the payer is enhanced at the cost of its role as a provider.

Is the government adding enough hospitals to the scheme? What about measures like ex-press empanelment?

Express empanelment of hospitals was initiated as a response to a need during the lockdown, to ensure that a sufficient level of non-COVID-19 critical health services capacity remains online. It was an emergency measure of the government, and reportedly it has worked. From 15223 in April 2020, the number of empanelled hospitals has grown to 24666 in December 2020, 46% of these in the private sector.

With lockdown and other restrictions, does it make sense to insist on e-card for beneficiaries of PMJAY? Or what role can technology play in PMJAY?

The number of new e-cards generated has undoubtedly gone down, but for a health insurance scheme of this scale offering portability of benefits, common identification is necessary. NHA will hopefully use lessons from the COVID-19 period to improve the scheme even further. Technology is currently used in areas from member management to fraud detection, and NDHM is expected to strengthen the scheme's digital backbone.

Lack of awareness about the scheme is still an issue. What can be done to improve this?

In a large and diverse country like India, a scheme will take time to have a particular recall value among the people, and in that sense, it is still maturing. Many people, particularly in rural areas, don't know about it. Highly visible, focused communication campaigns are needed to improve uptake. Once it is ensured that a sufficient number of hospitals are empanelled, authorities can launch active campaigns to improve awareness.

Active COVID cases are not so huge now. Do you foresee an emergency in the coming weeks? And would PMJAY play a crucial role?

The chances of another surge are low as of now, but it cannot be ruled out. PMJAY has played a vital role during the pandemic, but the scale has not been significant. It has focused on non-COVID-19 conditions more. I think that situation will continue unless there's a drastic change in the status quo, involving new virus strains.

According to a recent Oxfam report, the rich became more affluent, and the poor got poor-er during India's recent lockdown. It is now clear that the top 11 billionaires' income rise during the lockdown can fund the health ministry for the next ten years. What are the ur-gent pending reforms in the healthcare sector?

Getting the vulnerable middle class into PMJAY is the logical next step. Just under 60000 HWCs have been in place, and to reach the 1.5 lakh objective by 2022, the pace needs to be accelerated. The government has been trying to overcome supply bottlenecks in the health workforce using the expansion of government-owned institutions and also through public-private partnerships. Another crucial area where we need improvement is access to medicines. The government has been expanding Jan Aushadhi outlets. We need concrete steps to ensure the quality of generic medicines and change the public's perception – formed through many years of experience— that generic medicines are of low quality and price of a medicine is a proxy for quality.

India has never had public healthcare. Is insurance the only way to treat the underprivi-leged? How can we strengthen rural health infrastructure? So that people can use the access given by PMJAY?

India has always had free public healthcare – on paper. Insurance is a second-best solution. However, in the medium run, given that the government's capacity to create infrastructure is limited, leveraging a vast private sector is inevitable. Let us also note that a majority of Indian states have opted for the Trust route and not the insurance route for PMJAY. The poor in India have been waiting for publicly provided and financed universal health care for decades. If we depend on the public sector alone, that wait will continue for decades. India's private healthcare sector has been growing through implicit subsidies from the government and the sheer absence of "public" itself in the sector. Naturally, they must give back— at reasonable rates— to the society, through accountable systems. Perfect need not be the enemy of the good, and in India's case, the resulting wait will have horrible human costs. Remember, rural health infrastructure is being expanded at an unprecedented pace in parallel. It is undoubtedly not either-or, and we need to avoid falling in that trap.