Ayushman Bharat in Small Towns

Is Ayushman Bharat a success in small Indian towns? A HE Report.

Major public programmes are massive enterprises operating at gigantic scale made even more challenging in an extremely diverse country marked by poor infrastructure.

The critical delivery machinery of project and policy implementation that comprises the entire bureaucratic hierarchy is saddled with challenges from workforce shortage, to fit of capabilities, administrative problems, inherent biases, lack of proper incentives and monitoring.

Implementation improves when policy beneficiaries get to monitor it either through political channels (legislators) or civil society organizations (NGO).

Is Ayushman Bharat implementable or just noble?

The person on the ground is usually best suited to know about delivery if the why is well communicated. Seva Sadan Lifeline Super Speciality Hospital in Sangli is one of the top hospitals in the area. The hospital was set up two-three years ago and proved that corporate hospitals could thrive in tier II or tier III city. It has been able to survive because of the volume of patients. While the cost of the procedures like heart surgeries is 3.5 lakh in a city like Mumbai, in Sangli, hospitals like Lifeline do it for 1-1.5 lakh. "Ayushman Bharat enables poor patients to access care in small towns. Earlier, major cardiac procedures were available only in a few cities. Because of Ayushman Bharat, patients can get these treatments done even in a tier II city. Hospitals put up a kiosk to educate patients about services included in the scheme," says Dr Amruta Pathak, an intensivist at the hospital.

The state-run scheme, Mahatma Jyotiba Phule Jan Arogya Yojana and Aysuhaman Bharat are not merged in Maharashtra. So, 70 percent of patients are state-run-scheme beneficiaries, and 30 percent are from Ayushman Bharat scheme. "We don't get any incentives like subsidies on power tariff or water tariff from the local civic bodies. We need doctors to be part of the policymaking because the ground realities of running a hospital are often not conveyed to the government,” explains Pathak.

"We know what works, and it is just a problem of resources.”

Can flaws in the implementing structure be fixed?

Dr. Ravikant Patil, the founder of the hospital, notes that the scheme will be more successful in semi-urban and rural areas because the cost will be cheaper in those areas. "The consultation fee for a cardiologist in Mumbai is Rs 1000, in Sangli, it would be Rs 100, as the doctor in Mumbai would be seeing ten patients, but a doctor in a small town would see 100 patients. The cost will come down if more small towns are included in this,” he explains.

Dr. Patil also has several anecdotes to share about the financial impact of the scheme on impoverished patients. "I operated a carpenter in 2011, and he was not covered under any insurance scheme, so he had to borrow 1.5 lakh rupees. He had borrowed it at 12 percent interest from a local moneylender, and he is still paying interest. He couldn't afford a house, his children couldn't go to a good school. His brother got operated last month, and he got operated free of cost."

Are bureaucrats formulating policy keeping the implementing mechanism and reality in mind?

According to some doctors, there is an oversupply of doctors in metros. "There might be some 300 cardiologists in Mumbai. Top doctors might be doing surgeries. Others might not do so many procedures. Earlier superspecialists were not willing to work in metros. But now they are willing to work from rural areas, because of the excessive supply in cities," says a doctor.

Interestingly, the Cabinet Committee on Economic Affairs (CCEA) recently approved on Wednesday setting up of 75 government medical colleges, to be attached with existing district or referral hospitals, by 2021-22. The establishment of these medical colleges will add at least 15,700 MBBS seats in the country. The medical colleges will be set up in under-served areas having no such institutes. These medical colleges will to attached with district hospitals having at least 200 beds, a government statement said.

In fact, T Minister RS Prasad recently said that platforms like Aadhaar and UPI have a "global resonance" and politicians from Africa and the Middle East have told him that they're "keen to adopt these systems.” He added that registration and disbursal processes in India today are being done digitally, "based on homegrown technology – whether it is for Aadhaar, Ayushman Bharat, CAC, or BPOs in the small towns.” "We want India's digital economy to be a $1 trillion economy, and this shall be a part of the larger narrative of a $5 trillion economy, the minister said, before adding, "It is easily doable".

Should policy delivery be the responsibility of only the government?

But even a year after the rollout of Ayushman Bharat, news reports suggest that the Centre is struggling to close the last-mile gap as low awareness levels are proving to be a significant hindrance in states like Bihar and Haryana while Tamil Nadu has shown positive results, according to a survey conducted by the National Health Authority. The investigation has revealed that in Bihar and Haryana, the awareness level about Ayushman Bharat was less than 20%.

Ultimately there is no better way to monitor projects than to go by output or outcome rather than counting inputs. Implementing agencies are notoriously shy of beneficiary feedback while gathering it has become amazingly simple in today's age of information technology. Dr Anil Gupta, Head, Department of Hospital Administration, PGIMER, Chandigarh points out that the scheme is running smoothly, in India's second-largest medical university. "We are implementing the scheme from day one. We have admitted 2636 patients under the scheme in our hospital. In fact, the footfall is increasing every day. Cardiology, cancer and accident are the three categories where we get the maximum number of patients," he adds. Gupta adds that there are several challenges. "Sometimes, patients visit us thinking that disease is covered, but at times it is not covered.

Another problem is the reimbursement. If we incur a certain amount for a procedure, we get paid only 1/4th of that cost. Further, the value of the treatment is also often higher than packaging," Gupta concludes.

Are there lessons to be learnt from small towns?

In 2011, the wealthiest part of India, Chandigarh, enjoyed a per capita income similar to St. Vincent and the Grenadines, a comfortably middle-income country, while the most troubled region, Bihar with less than a quarter of Chandigarh's per capita income, resembled Eritrea, one of the world's poorest countries. There is not one India but many Indias with vastly differing income levels, varying needs, and diverse aspirations and expectations from policymakers. So, when you implement a scheme for the first time, it is crucial to take inputs from these "Indias", which are changing fast.