Ayushman Bharat has been rolled out as a health protection scheme that will provide guaranteed access to treatment that is free at the point of delivery to about 40% of the population selected on the basis of censused socio-economic indicators. It is the essential first step on the road to universal health coverage, although it has been launched by the NDA government quite late in its term, possibly with an eye on the 2019 general election. Since the Centre has announced that 10.74 crore families identified through Socio-Economic Caste Census data will be given an annual ₹5 lakh cover under the Pradhan Mantri Jan Arogya Yojana (the insurance component of the scheme), the question of eligibility appears settled. But the late start makes it virtually impossible for all those who are technically insured to avail of the services that state agencies must make available, within a reasonable time-frame. And, the allocation of just ₹2,000 crore during the current year to the PMJAY cannot provide the promised cover to the large population sought to be included. Not all States and Union Territories are in a position to raise their own share, and a few have not even joined the scheme. The challenge of funding, therefore, remains. And without adequate budgetary commitments, the implications of pooling the financial risk for such a large segment of the population through insurers or state-run trusts or societies make the outcomes uncertain.
Guaranteeing health-care access using private or public facilities presumes tight cost control. In the case of the PMJAY, this is to be achieved using defined treatment packages for which rates are prescribed. Costs are a contested area between the care-providers and the Centre, and many for-profit hospitals see the government’s proposals as unviable. In the absence of adequate preparation, the Ayushman Bharat administration is talking of a rate review. More importantly, a lot of time has been lost in the NDA government’s tenure, when State governments should have been persuaded to regulate the hospital sector under the Clinical Establishments (Registration and Regulation) Act, which dates back to 2010. The law broadly provides for standardisation of facilities and reasonable rates for procedures. Apprehensions of fraud have prompted Ayushman Bharat administrators to announce that some key treatments should be availed through public sector institutions. But public facilities have been neglected for long. Going forward, there are some clear imperatives. It is essential to reduce the pressure on secondary and tertiary hospitals for expensive treatments by investing in preventive and primary care facilities. Here, the 150,000 health and wellness centres of the National Health Protection Mission can play a valuable role. The first-order priority should be to draw up a road map for universal health coverage, through continuous upgradation of the public sector infrastructure.
