How has Ayushman Bharat Scheme fared during COVID?
Soumyadeep Bhaumik, is a medical doctor and international public health specialist working on evidence synthesis , injuries and policy impact at The George Institute for Global Health, India. In an exclusive interview with Healthcare Executive Magazine, he shares his views about PMJAY.
How can we address the issue of lack of government investment in terms of equipment, facilities and staff at public hospitals?
The less than 1% of GDP being invested in healthcare for decades, is now manifesting as 24% fall in overall GDP as a result of non-resilient health systems which cannot handle a pandemic . Massive investment on public health infrastructure, drugs and doubling salaries of all underpaid healthcare workers – particularly junior doctors , nurses , paramedical staff and ASHAs is will have triple benefits – making our health system ready for COVID-19 , alleviating the suffering of the common man and triggering consumer spending in a sagging economy. The more we delay investment in public health facilities – the larger will be the number of deaths and suffering and harsher will be the impact on the economy. Private hospital capacity is not a solution as we have seen how large corporate hospitals ,and smaller ones alike, used the opportunity for predatory pricing causing immense hardships to the poor and middle class.
Despite state governments announcing treatment being free, many corporate hospitals refused to come on board in states like West Bengal. How can this issue be addressed?
It is indeed tricky as private entities are independent. However, many corporate hospitals had promised free care in exchange of land being allocated at throwaway prices. Contractual obligations as such might be used to enforce free treatment for all patients (not just COVID-19) for such hospitals.
Governments might also consider using existing provisions of the Disaster Management Act to nationalize all large corporate hospitals whose actions are grossly harmful for the health of the nation. Taking over corporate hospitals immediately and making them government hospitals in the only way out. Frankly, I see this as the only way out from the conundrum we are now in with the triple whammy or a pandemic, economic depression and border conflicts.
Rates have always been an Achilles heel for policymakers in India. Is it easy enough for a government to do it? Has the Ayushman Bharat scheme helped the poor?
Rates for and will always be a challenge in a scheme like Ayushman Bharat. The government should commission independent not-for-profit research organizations to do proper costing studies to decide on rates for all conditions and all scenarios. This should be preceded by proper clinical practice guidelines and building a legal framework around it. This is not a very complicated task and is an essential for any scheme of this nature and some work on this is already being done but the need is to expedite it and build legal frameworks around it. Merging all investment schemes starting with CGHS and any other by PSUs into Ayushman Bharat is a good starting point to test the rates and then slowly move forward. If the government is the major buyer of health services it can prevent private players from overcharging . An evidence-based approach with calibration is essential.
Again, the equity perspective of Ayushman Bharat can only be known if evidence on it is available. All data from Ayushman Bharat as well as other data like that from Surveyor General office , inan anonymous, de-identified manner, should be made available to researchers in Indian institutions through a registered portal . Currently these are not available at all or away from public scrutiny owing to legal contacts with foreign research institutions. As a scientist I cannot say whether it is working for the poor or not without seeing evidence. But the design means that it might be helping to some extent.
Is it right to expect private healthcare providers to shoulder all the responsibility in a pandemic? What can a scheme like Ayushman Bharat do?
As mentioned earlier – providing health, just like providing security at the border is a basic government function and there is a need to nationalize all corporate hospitals. What use is an army if it cannot fight a battle? What use is the private sector if it cannot shoulder all the responsibility during the pandemic?
We have seen how nationalization of banks has helped our economy in the long run. Let’s do the same for the health system, nationalize all corporate hospitals and help the poor.
Does the pandemic offer a unique opportunity for radically transforming India's healthcare system as Amitabh Kant recently pointed out?
Yes, it is a unique challenge and I agree that the right approach to deal with it is seeing it as an opportunity to reform. An immediate 10% of GDP being invested on health is required with 1% of GDPbeing reserved for health research. This will kick-start the economy and create jobs – as for example an army of contact tracers is required. Apps cannot replace the footwork of contract tracing and it does not create jobs. Let's use the money on health to employ people who have lost jobs.
Creating more primary healthcare services in villages and upscaling them so that people do not come to cities is crucial. We need de-urbanization because right now if you look if we look globally (and similar in India), 55% of the population lives in the cities and it will increase to 65% by 2050 . So be it economic systems or health systems- they are concentrated in cities. It is a failure because we are not focusing on the rural sector and people. Pandemics spread very fast in urban cities. Whether we like it or not, this might not be the only pandemic we are seeing in the next 50 years and the next one could be complicated further with climate change. Not investing in health now will mean ongoing economic loss with risk to further economic slow-downs, and keeping us exposed to losing out during health emergencies.
So Yes, I agree with Mr Kant that we must seize the opportunity to evolve and change. We really need to start investing in health , and the monies used for de-urbanization of our economy, and health systems through massive investments in our primary healthcare systems .
The de-urbanisation of the economy and the health system will have to be twinned - moving jobs and people and rural areas and developing rural public health systems. A de-urbanised country will be not only be pandemic resilient but will also solve our pollution woes and safeguard against climate change.
Some hospitals under Ayushman Bharat have also been attempting fraud over COVID-19. How can such issues be addressed?
I am not a fraud expert, but I think, criminal charges and quick punishment for hospital owners and top managerial staff might act as deterrent for such rogue hospitals
Can technology play a role in making things better?
The short answer to this is yes and no. Technology can definitely play a role but with the basics not in place it should not be a priority at all. We can build fancy apps , integrate AI to predict things and look at data but what do we do with this information ? Our system has pressing priorities like ensuring oxygen supply, medicine and diagnostic supply and proper pay for health workers. The utility of technology in making lives better is very contextual and at this point we need to think whether it is acting as a “disruptive innovation” or “distraction”. We need to get our basics right in public health facilities–once we have them technology will be a key enabler.
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