Predictably, the Ayushman Bharat (AB) scheme is the centerpiece of this year’s budget allocation towards health. It accounts for almost Rs 8000 crore of the total health outlay, which is Rs 63,298 crore. Approximately 12% of the health budget.
While Rs 1600 crore from the AB budget has been allotted to Health and Wellness Centres, the provision to upgrade primary health facilities, the ambitious Pradhan Mantri Jan Arogya Yojana (PMJAY) has gotten the lion’s share, at Rs 6400 crores. A further Rs 156 crore will be diverted to PM-JAY from the existing Rashtriya Swasthya Bima Yojana (RSBY), taking the figure up to Rs 6556 crore.
The commitment is a step in the right direction: to deliver in-patient care and help reduce illness- related impoverishment, especially in rural India.
However, given the proposed scale of coverage, the PMJAY (Pradhan Mantri Jan Arogya Yojana) budget falls short of the commitment. The original idea was to provide health insurance cover of Rs 5 lakhs each to 10 crore families, around 50 crore people. As experts have estimated, based on the number of hospitalizations and out of pocket expenditure recorded in NSS health data 2014, and considering an annual inflation rate of 5%, the present PMJAY budget of Rs 6556 crores (including RSBY) is unlikely to cover even one-fourth of the target. In other words, even a budget of Rs 10,000 crore for 10 crore families to be covered by the scheme would translate to a cover of Rs. 1,000 per family.
Touted as the world’s largest government-funded healthcare programme, the scheme has undergone several layers of public scrutiny, and in detail.
Analyses and conclusions drawn by experts, intellectuals, and political leaders, have frequented news space, and as a consequence it has softly, but definitely, emerged as a favorite talking point. Given the scale of the beneficiary outreach, much of the debate has been around the level of commitment versus the announcement.
The big positive that has come off this increased discourse is health being framed as a high-level policy item. Despite hard facts and obvious merits, health issues and health policies have not grabbed eyeballs for too long or been discussed at this scale, ever.
As the deliberations are expected to carry on for some time, this might be the right time to raise a few pertinent points that continue to ail the public health sector for years on end.
Short-Sighted Government Vision
The government’s vision (not just this one but its predecessors as well) has so far remained short-sighted to the need for comprehensive primary care. People living in rural areas in general and remote ones in particular, who are mostly affected by infectious and easily preventable diseases, are deprived of fully functional clinics leave alone accredited hospitals. Public health facilities in the country are currently inadequate and lack resources.
For much of rural India and its most disadvantaged people, provision of primary health care is the first and only point-of-care. The current lack of focus on preventive-promotive health has overburdened secondary and tertiary hospitals and led to inefficient and expensive health care. In 2011-12, the out of pocket expenditure on health led to 55 million Indians being pushed into poverty.
No Safety Net For Several Chronic Ailments
Disease profiles vary across the country and several chronic ailments like respiratory tract infections, heart diseases and diarrheal diseases, are managed and mostly addressed through out-patient consultations. Most of the poorest states in the country are reeling under high disease and economic burden from such ailments. Unfortunately, the scheme doesn’t provide a safety net to this group.
Clear Lack of Funds
Although Ayushman Bharat promises to develop health and wellness centres, the initiative has been grandly overshadowed by PMJAY. A meagre allocation of Rs. 1600 crores this year, the vision to reform 1.5 lakh health facilities into health & wellness centres, is barely enough. As experts estimate, the annual spend on each centre would total approximately Rs.15-16 lakhs, which translates to the scheme costing Rs. 23,000 crore annually. The project is clearly underfunded.
The other big challenge in service delivery is the severe shortage of doctors and medical staff, with up to 40 per cent of health worker posts lying vacant in some states.
As per National Health Profile-2018, a government doctor serves a population of 11,082, which is much higher than the WHO recommendation of 1:1000.
Unmet Need for Cataract Surgeries
Recent reports suggest that cataract surgeries have been the most sought-after procedure under Pradhan Mantri Jan Arogya Yojana (PMJAY). This also underlines the unmet need for cataract surgeries. A total of 2,46,900 claims were submitted for cataract surgeries under PMJAY. This has happened despite the National Programme for Control of Blindness and Visual Impairment (NPCBVI), doing it for free it since it was first established in 1976.
Historically, primary healthcare services in India have always been plagued by shortage of human resources, lack of infrastructure and the capacity to cope with the epidemiological complexities of the infectious diseases. These factors augmented by economic capacity of the marginalized, have collectively resulted in lack of confidence in the quality of available care in rural areas.
While we need to be patient with certain policies taking shape and moving in the direction intended, the need of the hour is to improve primary healthcare and to increase public spending on health.
It is understandable that curative health care grabs greater attention than preventable since the government of the day is always able to grab brownie points from the “lives saved” in epidemiological situations rather than the “lives that may not have been lost” in preventive care.
By now it has become a cliché to compare India’s Defence budget with those of its counterparts in the social sector. The Defence Budget in 2019 has crossed the Rs 3 lakh crore mark for the first time. This is not to say that the country can afford to be complacent despite the fact that India has fortunately not been engaged in a full-blown war for years.
However, disease, especially preventable disease and the deaths that arise from these is still among the highest in the world, a war within the country that literally needs to be dealt with on the proverbial “war footing.”
(Anikendra Nath Sen is a senior journalist who shuttles between India and Nepal)
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