New Delhi: On August 17, a baby girl was born in a government hospital in Haryana, the first to be born under the Modi government’s Ayushman Bharat insurance scheme. The government’s scheme reimbursed the government hospital with Rs 9,000 for carrying out the delivery of this child by a caesarean section.
https://t.co/uolwFN6ZpY Ayushman Bharat baby!
— Dr. Indu Bhushan (@ibhushan) September 1, 2018
The Ayushman Bharat insurance scheme – which intends to provide a health insurance coverage of Rs 5 lakh to ten crore families, with the money being split between as many people as there are in that family – was announced by finance minister Arun Jaitley in February.
Creative thinking and strategic marketing
Initially, the government refused to call this an insurance scheme, marketing it instead as the “world’s largest healthcare programme”. In his Budget speech, the finance minister used the word ‘insurance’ while refering to several government programmes, including PMJJBY, PMSBY, Jan Dhan Yojana, PMVVY as well as when talking about other public sector undertakings and senior citizens. But the use of the word “insurance” was conspicuous by its absence when describing the Ayushman Bharat scheme.
Not the largest healthcare programme
Between India and China’s immense populations, the title for “largest” is likely to go to one of these two countries. While India is claiming “largest” on this programme, there are more routine, less-glitzy health programmes which are also called “largest”, such as the deworming programme.
One of the largest public health programs in the world- #NationalDewormingDay.
School kids getting deworming tablet at a school in Begampur, #Bihar. #SwasthaBharat #AyushmanBharat @JPNadda @AshwiniKChoubey @AnupriyaSPatel pic.twitter.com/RaUVfeT7j6— Ministry of Health (@MoHFW_INDIA) February 19, 2018
The Ayushman Bharat scheme also does not provide healthcare/health insurance to all Indians – only for about ten crore families, or an estimated 50 crore individuals, whose names feature in the socio-economic caste census. The last such census was done in 2011, eight years ago. Aadhaar is the first and primary document which will be used to “verify” people. As a document, it has already proven to be exclusionary rather than inclusionary for people trying to access their rights, benefits and entitlements in India.
Government hoping to generate demand instead of providing supply
Government officials have explained this scheme as being one that will incentivise private players to “go where the money goes”. The government is hoping that by creating a pool of demand for healthcare, with people in the lowest class sections of society asking for it, private players will put in the money and take on the risks of investing in healthcare for them. The logic expects for private players to flood in while the state recedes.
Urging all eligible private hospitals to empanel with Ayushman Bharat. We are are offering you business of 50 crore people! #AyushmanBharat
— Dr. Indu Bhushan (@ibhushan) July 23, 2018
This may not actually be the case. In other private-public experiments by the government, we have seen that the private sector does not want to go the last mile, and in some cases like in Rajasthan, as reported by The Wire, they have promised to set up healthcare in far-flung areas, even take resources from the government for it, but then don’t actually follow through.
Universal health insurance through private hospitals has not worked for the poor anywhere. Biggest beneficiaries are the private hospitals and insurance companies. There is no substitute for public health care. More money should have been pumped to strengthen it.
— Dr Arvind Mayaram (@MayaramArvind) February 1, 2018
Same scheme, different names
The government has spent considerable attention on naming, branding and posturing the scheme.
The scheme’s names – in order – have been: Rashtriya Swasthya Bhima Yojana (RSBY), Rashtriya Swasthya Suraksha Yojana (RSSY), National Health Protection Scheme (NHPS), Ayushman Bharat, Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSSM), Pradhan Mantri Jan Aroygya Abhiyaan (PMJAA) and Pradhan Mantri Jan Aroygya Yojana (PMJAY).
The contours as well as the name of the scheme have gone through rejigs. Government officials have said this is because their earlier vision for the scheme was not “aspirational enough.” While the RSBY offered a cover of Rs 30,000, the earlier announcement by the same government had promised Rs 1 lakh of a cover and the current “aspirational” iteration is offering Rs 5 lakh.
Rates offered by government seem arbitrary
The government has floundered on the issue of how package rates for reimbursement of hospitals have actually been fixed and what research they have taken into account. Despite pressure from various doctor and hospital lobbies, earlier this year, the government said the reimbursement rates are “frozen,” much to the anguish of lobby groups who found the rates too low.
However, later, the government said that they had not actually done a costing study and that they would begin one and it could take three years.