Something is severely amiss
Ayushman Bharat has several pitfalls which raise pertinent questions on its credibility
Just like other slogans, expectations have been raised from the highly advertised National Health Protection Scheme (NHPS) – the Ayushman Bharat, rolled out by the Prime Minister on September 23, in Ranchi. It is said to be the biggest health insurance scheme in the world. Therefore, it is important that the scheme is reviewed to see whether it will provide universal comprehensive healthcare to the citizens of our country.
The scheme will cover 10 crore families that are 50 crore people with a coverage of Rs five lakh for secondary and tertiary hospitalisation care. With India's population hovering around 130 crores, this means nearly 80 crore people will be left out of any coverage benefit. Very few of this uncovered 80 crore population has resources enough to effectively support their healthcare needs. The income limit for households for qualifying as a beneficiary under the BPL (below poverty line) list is at about Rs 27,000 per annum. A household with an annual earning of more than Rs 27,000 will stand excluded from the BPL list. The upper limit has been arrived at by allowing five earning persons in a household with a per capita monthly income of about Rs 447/- per month in the rural areas, which works out roughly to Rs 2,250 per month per household. This is too meagre an income to meet basic needs for a healthy life. Large numbers of our population are little above this level, who are unable to support their basic healthcare needs and who would be devoid of any benefit from the Ayushman Bharat.
Since the scheme will cover only the hospitalised patients and not the outpatient care or the preventive healthcare, it does nowhere meet the criteria of comprehensive universal healthcare. Nearly eighty per cent of the time, the out-of-pocket expenditure of patients is on outpatient care which is not covered under NHPS. It is also not clear whether post hospitalisation, expenses will be met by the insurance companies or by the patient. In many diseases, post hospitalisation care is very expensive and lifelong.
Senior citizens are the most vulnerable population who need continuous care and empathy. Most of the diseases that occur at this age are chronic in nature, which demand repeated visits to doctors at a time when the earnings have come down substantially or have become nil. In the absence of coverage of OPD care, even those who will be enrolled in the NHPS, will not benefit much. Elderly have special nutritional needs which need to be fulfilled. In the Ayushman Bharat, there is no such mention of these requirements.
The social determinants of health such as the supply of clean drinking water, adequate sanitation system, proper housing, nutrition, sufficient wages to meet these day to day needs, and health education are the primary factors related to healthcare. However, in practice, these determinants are not integrated into the government's policymaking.
Making of toilet sounds good but it has to be monitored. Since in most of the cases the toilets are not connected to the sewer lines in the rural areas, there have to be holes to collect the excreta. This needs proper maintenance in a scientific manner. Just putting one-time seat may not serve the purpose. In 'kucha' dug holes there is seepage of soiled water causing pollution of the drinking water in the nearby vicinity. Many such toilets are not being put to the desired use; some are being used as storehouses. The government gives Rs 4000/- for construction of such toilet. In fact, this amount is too low. Minimum cost to build a toilet of the size of 5 x 5 feet will not be less than Rs 12000. To construct a toilet of this size, a minimum of 800 bricks is needed @ Rs5/- per brick. If Rs 8000/- has to be contributed by the person himself then it is unlikely that each and every family will build toilets.
Nutrition plays the most important part in health. A well-nourished person is less likely to be ill compared to the one with poor nourishment needs no explanation. For proper nourishment we need a balanced intake of proteins, carbohydrates, fats, vitamins, and minerals, etc., All this comes from daily intake of staple food like wheat/rice, vegetables, meat, eggs, milk, fruits, etc. As per calculation for a daily intake of 2100 calories through a balanced diet for an adult, the cost comes to around Rs 90/- per day at the present rate of prices. For a family of 5, it requires Rs 13500/- per month for food alone. With falling wages, insecure jobs, and contractualised employment, all this is a pipe dream for the vast majority. Thus, most of our population remains undernourished.
Housing is another issue which is an important determinant of the health of a person. One's longevity depends much on the environmental conditions one lives in. With large numbers of our population living in shanty houses, it would be naïve to expect them to be healthy.
It is well known that the insurance companies' primary motive is to earn a profit. It is presumed that since the number of people insured in the NHPS will be very large and since at any given time very few people are hospitalised, this will give enough scope to the companies to reap profits. But if at any stage the companies find it to be unviable, they would not hesitate to pull out on one excuse or the other. If the premium is low then many of them may not join the scheme at all.
Those not covered under the scheme will be left to the mercy of insurance companies whose coverage is premium based. More the premium, more the coverage! The premiums have become very high and out of reach for most of our population. For example, a family of five with three senior citizens has to shelve around one lakh rupees annually as a premium to get a coverage of 5 Lakh rupees, even in the public sector insurance companies. This is impossible for most of those uncovered under NHPS.
The concept of universal comprehensive healthcare was primarily practised by the former Soviet Union who in the Soviet constitution 1936 guaranteed that the Citizens of the USSR have the right to health protection. According to the Article 42 of the Soviet constitution 1936 "This right is ensured by free, qualified medical care provided by state health institutions; by extension of the network of therapeutic and health-building institutions; by the development and improvement of safety and hygiene in industry; by carrying out broad prophylactic measures; by measures to improve the environment; by special care for the health of the rising generation, including prohibition of child labour, excluding the work done by children as part of the school curriculum; and by developing research to prevent and reduce the incidence of disease and ensure citizens a long and active life."
Likewise, healthcare in Britain is mainly provided by its public health service, the National Health Service, that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid from general taxation.
Much needs to be done to ensure healthcare for all. The social determinants have to be taken care of while talking about healthcare. For this public spending on health, which is a meagre 1.04 per cent of the GDP at present, has to be increased to at least 5 per cent of the GDP. Sufficient funds have to be released towards the schemes to meet the requirements for nutrition, housing, water supply, sanitation, and health education, otherwise, the Ayushman Bharat will also meet the same fate as Swachh Bharat Abhiyan.
(Dr. Arun Mitra is Senior Vice President, Indian Doctors for Peace and Development. The views expressed are strictly personal)