Abandon the AB-PMJAY scheme based on the discredited insurance model
The recent announcement regarding the launch of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme has raised expectations that the scheme will somehow address the extremely urgent needs regarding healthcare in the country. Expectations have also been raised because of the labeling of the scheme as the ‘largest health protection scheme in the world’ and the promise that beneficiaries will receive Rs.5 lakhs as cost of hospitalization.
The Jan Swasthya Abhiyan wishes to point out that the mere assertion that the AB-PMJAY is the largest health protection scheme in the world, does not make it so – in fact it is entirely misleading. The Government’s own National Health Mission has an outlay of around Rs.35.000 crores, many times more than the Rs.2,000 crores allocated for the scheme in the 2018-19 budget.
The Jab Swasthya Abhiyan is deeply concerned about the haste with which the scheme has been conceived and announced, without regard for the negative experience with existing insurance schemes such as the RSBY. The AB-PMJAY is based on the discredited ‘insurance model’ despite massive evidence against the effectiveness of such insurance based schemes involving major participation of the private sector in service delivery. There are also serious doubts regarding the viability of the programme given that this year’s budget provides only a token allocation for the scheme.
The AB-PMJAY, like its predecessor the RSBY scheme and several state level schemes, is to provide insurance cover for hospital based care. The enhancement of cover to Rs.5 lakhs has been continuously stressed while publicizing the scheme. However, past experience shows that an overwhelming majority of claims under insurance schemes are actually in the region of 10,000 to 50,000 rupees. Thus the raising of the limit to 5 lakhs will not translate into a windfall for patients, as we are being led to believe.
Public funded insurance schemes like the RSBY have failed to make even a small dent as regards access to healthcare services. Data about the RSBY shows that only a fraction of projected beneficiaries were actually enrolled. The even more important concern has been about the quality of services provided and clear evidence that the scheme was being milked by unscrupulous private providers to profiteer, often by doing unnecessary procedures and ignoring real needs. Horrendous reports of misuse involving the conduct of unnecessary hysterectomy (uterus removal) operations in women as young as 23 years old have emerged from different parts of the country. It needs to be underlined that the scheme is being rolled while both the Central and State Governments have shown no interest in implementing robust mechanisms for regulation of private medical facilities. The Clinical establishments Act, passed by Parliament several years ago, is yet to be implemented meaningfully in any part of the country. At the same time repots surface regularly of incidents of gross negligence, malpractice and overcharging in private facilities in different parts of the country. A majority of facilities empanelled under the RSBY scheme were private (4,291 out of 7,226) and the same trend can be expected to continue in the new scheme. The Niti Ayog claims that the AB-PMJAY will be 17 times bigger than the RSBY scheme but the moot question is: how can we expect the same government to effectively run a much larger scheme when it failed entirely in case of the RSBY scheme and several state level schemes. The direction of the AB-PMJAY would thus be of, as earlier in the case of public funded insurance schemes, indiscriminately using public resources to strengthen an unregulated, and in several instances corrupt and negligent, private health care providers.
There are also serious doubts regarding the real intent behind the hasty announcement of the scheme at a juncture when several state level elections and the national elections are just a few months away. The scheme has been announced without an adequate provision for its funding in the 2018-19 budget. By the finance ministry’s own admission an annual outlay of Rs.12,000 crores will be required to fund the programme, while independent estimates put the figure much higher – at around Rs.50,000 crores. What has however been allocated in the 2018-19 budget is a pittance in contrast – just Rs.2,000 crores. This raises the suspicion that the announcement regarding the scheme has more to do with attempts to score a political point rather than a real intent in addressing urgent healthcare needs of the Indian people.
Further the scheme will only cover hospital based care, while data shows that the bulk of expenditure that patients incur is on conditions when they are not admitted to hospitals – such as patients receiving care for TB, cancers, etc. An associated announcement has been of the plan to strengthen 1.5 lakh primary level centres, now to be named “Health and Wellness Centres”. In itself this is welcome as it would strengthen public services. However the 2018-19 budget has allocated a meager Rs.1,200 crores for this purpose, which would possibly suffice to meet just 5% of the need. We are again concerned about the intent of this announcement – whether a mere ploy to garner electoral benefits or a real attempt at strengthening public services.
The Jan Swasthya Abhiyan urges the government not to view decisions regarding healthcare as opportunities for ensuring electoral success. We note that successive budgets – especially over the last 4 years — have contributed to the serious underfunding of the National Health Mission, tasked essentially with strengthening public services. We demand that the government abandon plans for the AB-PMJAY. The projected annual outlay of Rs.12,000-50,000 crores, as per different estimates, would be much better utilized by investment in expansion of public facilities and creation of permanent public assets. Feeds by publicity agencies of the government, to news agencies, about a few hundred people who are benefiting from the new scheme are not a substitute for meeting the healthcare needs of crores of people across the country.
Issued on Behalf of Jan Swasthya Abhiyan.