The Directive Principles of State Policy in Indian Constitution directs the state to raise “the level of nutrition and standard of living of its people and the improvement of public health as among the primary duties”. But, at the same time, the total health budget of India is just 1.29% of GDP, which is very low among the health expenditure of developed and developing countries. The unparalleled COVID-19 pandemic has now laid down the necessity to increase the investment in public health infrastructure and medical research.
The first National Health Policy(NHP) in 1983 adopted “an integrated comprehensive approach towards the future development of medical education, research and health services” and also envisioned the goal of “Health for All by the Year 2000 AD”, which for the first time envisioned the idea of universal health care(UHC) in India.
Ayushman Bharat-PMJAY scheme was launched in 2018 as a successor of National Health Protection Scheme (NHPS), keeping in sight the “policy principles” highlighted by third NHP in 2017. It has two components of infrastructure building and policy delivery-framework, as mentioned below respectively.
HWCs provide “expanded range of services” spanning maternal and child health care, care of non-communicable diseases and communicable diseases like tuberculosis, dental, ENT, eye, mental health and first-level care for emergencies and trauma.
CEO of Ayushman Bharat-PMJAY, Mr Indu Bhushan, in an interview with Economic Times said that “40% of expenditure is going to public sector infrastructure”. But health expenditure in India is already very low. The budget allocation for Ayushman Bharat in FY20 is 6400 crore and 40% of it would be insufficient to develop quality infrastructure where government hospitals have scant infrastructure and facilities.
NHP 2017 suggested to “align the growth of the private health care sector with public health goals” to fill the “critical gap” in the reach of health services and to “incentivizing private sector”. Ayushman Bharat PMJAY emphasized this by incorporating private hospitals to provide health care for which they are reimbursed by the government.
COVID-19 pandemic has revealed some ambiguities in the PPP model. In a policy brief of NHA issued in June 2020, it came out that weekly claim of PMJAY was reduced by 51% during the lockdown period. It was also admitted in the report that “private hospitals reduced services out of fear of COVID-19 infection among health workers” and due to the concern that their “business outlook will be jeopardized if they are perceived to be treating COVID-19 patients” (Policy Brief: PMJAY under Lockdown. Evidence on Utilization Trends, June 2020).
One of the prime features of Ayushman Bharat PMJAY is the interstate portability which allows the residents of one state to take the benefit of the scheme in any of the states and UTs. Currently, all the states and UTs, except West Bengal, Orissa, Delhi and Telangana (having their own similar state-level schemes) are on board of PMJAY. Interstate portability has now a feature of central schemes such as “one nation one ration card”.
Interstate portability can be very advantageous for migrated labourers in states like Maharashtra, Gujarat, Haryana and Punjab. It is also helpful when some ‘specialist facility’ is not available in one state, it can be accessed in another state. However, the statistics of NHA (National Health Authority) are not so encouraging. Consider the following table depicting the number of interstate portability in ‘labour importing’ states.
|Patient State*||Hospital State*||Number of Portability*|
*Source: NHA database
These figures are so small when compared with a large number of migrants in the “hospital states”. One of the reasons can be the lack of awareness among people about the scheme. However, ‘migrant importing’ states are more developed and can provide better services and can reduce the burden on backward states.
Secondly, the number of hospitals empanelled into the scheme is also inadequate. Let’s take a few examples. The number of hospitals empanelled in Maharashtra is only 812, which is the third-largest state in terms of size and second in terms of the population whereas Bihar has 871 hospitals, which is twelfth in terms of size and third in population. Uttar Pradesh which is the most populous state has slightly less number of empanelled hospitals than Gujarat which has a smaller population.
This inconsistency needs to be addressed. Lastly, some technical glitches are also noted with the system as there is no single tracking management system across the states with a user-friendly interface.
Recently, after the large scale reverse migration of labourers due to lockdown, the government has initiated to prepare a list of migrants who have returned. However, PMJAY is using the Socio-Economic and Caste Census (SECC), 2011 as a base document, there is no requisite tracking mechanism to bring all migrants into the coverage area of the scheme.
There is an urgent need to include counter-pandemic framework within the comprehensive integrated National Health Policy. Shortage of beds and ventilators due to COVID-19 can be fulfilled with private hospitals but they are not ready to collaborate due to above-mentioned reasons. NHA, however, on 4th April 2020, decided to incorporate COVID-19 treatment under PMJAY. But as figures have shown a 51% slump in overall claims, demand was again very low for COVID-19 testing and treatment under the scheme. So, public health infrastructure has to be strengthened with more investment, in spite of over-reliance on the profit-oriented private sector.
Can we include ‘pandemic’ under universal health care?
The idea comes when Supreme Court of India asked the government to fix the rates of COVID-19 testing for all in private labs and hospitals, which was strongly opposed by private firms. The cost of testing and treatment in ICU and ventilator is very high in private hospitals which should be capped as the rates of heart stent were fixed earlier. UHC means to make the healthcare services affordable for all, which requires strong policy decisions beyond Ayushman Bharat.
This is the testing time for the health policy of India for its preparedness for the future and also to review certain areas. In the wake of COVID-19, Ayushman Bharat has now two prime focuses of public health infrastructure development and to increase the coverage area through better tracking of downtrodden sections.