Soham D Bhaduri
Universal well being coverage (UHC) has received an unprecedented systemic push more than the previous decade, reinforced significantly by the Sustainable Development Goals. In India, the public well being insurance coverage (PHI) route has been strongly sophisticated as the prime agency for attaining UHC—founded on the expertise of the multitude of state and national PHI schemes stretching considering the fact that the early 2000s. The most current in line is the Pradhan Mantri Jan Arogya Yojana (PMJAY), hailed as the biggest well being assurance programme in the planet, covering more than 50 crore poor Indians for hospital expenditures upto `5 lakh per annum.
Recent policy pronouncements have clearly bespoken the present government’s intent to make PMJAY the face of UHC expansion in the nation. Calls for expanding PMJAY to the remaining uncovered population have especially picked up pace in the context of Covid-19. However, pushing this laudable objective working with incongruous representations and askew interpretations would be least warranted. It is in this respect that the Economic Survey 2021 tends to disappoint.
The Survey ends up working with an array of inapposite well being indicators in studying the scheme’s effect. This involves indicators that do not appear relevant to assessing any hospital insurance coverage scheme (for e.g., sex ratio at birth, years of schooling, youngster vaccination), and ones that can only weakly be linked with hospital insurance coverage (for e.g., maternal and youngster well being care). Two relevant indicators would have been mortality prices from illnesses covered beneath insurance coverage, and the extent of economic danger protection afforded to beneficiaries, but they lack even a passing mention. Protection from catastrophic hospital expenditures incurred due to extreme illnesses has been the prime objective behind rolling out the PMJAY and other PHI schemes. What is ironic is that one of the couple of somewhat-connected indicators, viz. institutional births, has really been identified to be superior in non-PMJAY states (like West Bengal) than states implementing PMJAY.
The incredibly basis for working with NFHS-5 information is questionable. The NFHS-5 (2019-20) phase 1 truth-sheets study explicitly that the PMJAY may possibly not have been rolled out totally at the time of the NFHS-5 survey, and hence, may possibly not have been reflected in its well being insurance coverage coverage estimates. It is far-fetched to consider that PMJAY, which was rolled out only in September 2018, could have considerably impacted distal well being indicators like infant and youngster mortality inside such a quick time. For e.g., in 3 PMJAY states which have been studied (Assam, Bihar, and Sikkim), the NFHS-5 fieldwork was undertaken anyplace involving June 2019 and February 2020. One also finds assumptions about comparability and similarity involving the studied states (West Bengal and its 3 neighbours pointed out earlier) to be discomforting. Their spatial contiguity has been held to imply a concomitant similarity in demographic and socio-financial profiles. The financial survey attributes the decline in well being insurance coverage coverage in West Bengal, and a concomitant enhance in its neighbouring states (Assam, Bihar, and Sikkim), to PMJAY. However, one need to note that the significant chunk of the enhance in the neighbours is accounted for by just one state: Assam, which recorded a dramatic enhance in insurance coverage coverage from 10.4% (NFHS-4) to 60% (NFHS-5). Bihar saw only a little enhance (12.3% to 14.6%), even though Sikkim really registered a decline in insurance coverage coverage (30.3% to 25.7%). Also, one can’t dismiss the most likely function of the Atal Amrit Abhiyaan (AAA), the state PHI scheme of Assam, which has a bigger beneficiary base than PMJAY, in majorly pushing up the insurance coverage coverage figures for Assam. The AAA was rolled out in 2016-17, a couple of years ahead of PMJAY, and is for that reason, most likely to have been superior captured than the latter in the NFHS estimates.
Finally, the Survey ignores particular fundamentals when it comes to PMJAY and hospital insurance coverage. It shows that the highest quantity of insurance coverage claims beneath PMJAY comes from comparatively affordable procedures, and argues that this could indicate PMJAY becoming made use of as a delivery channel for main care services, or even as a substitute for the latter. The truth, nevertheless, is that PMJAY covers not main, but secondary and tertiary care (outpatient consultation is covered if it leads to hospital admission), and substituting main care with hospitalisation is a very undesirable finish that is antithetical to the single most vital purpose of well being systems—to halt illness progression in its early stages. Further, even though fewer claims for highly-priced procedures could indicate fewer malpractices such as cream-skimming, it could also imply that the scheme is not catering adequately to its main objective of safeguarding against prohibitive hospital bills.
The PMJAY could be a valuable tool for a a lot-necessary healthcare expansion in India, but a scramble to push it shouldn’t lead to adoption of awry, indefensible strategies for demonstrating its effectiveness. Besides amounting to mere self-flattery, it could seriously erode public faith in the otherwise promising programme.
Chief editor of The Indian Practitioner and a doctor-researcher based in Mumbai. Views are individual