India has earlier tried out national insurance models such as the Rashtriya Swasthya Bima Yojana (RSBY) that started in 2008, aiming to cover hospitalisation expenses upto Rs 30,000 for families below the poverty line. Its overall performance was poor and the scheme failed to reduce impoverishment.
In September 2018, Prime Minister Narendra Modi launched the ambitious Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the National Health Protection Scheme, in Ranchi, Jharkhand. The scheme that subsumed RSBY provided an insurance cover of Rs 5 lakh to 100 million ‘poor and vulnerable’ families identified by the socio-economic caste census (SECC) of 2011.
More than a year later, we spoke with Indu Bhushan, the chief executive officer of AB-PMJAY and the National Health Authority (NHA), which is responsible for implementing the scheme.
“We have gone beyond RSBY,” said Bhushan, sitting in his seventh floor NHA office on New Delhi’s Janpath. By December 2, 2019, PMJAY has covered over 6.8 million hospitalisations worth Rs 7,160 crore and has issued over 67 million e-cards to beneficiaries, according to PMJAY website and NHA. It is present in all but four states--Odisha, Telangana, West Bengal and New Delhi.
Pointing to the large screen showing the PMJAY dashboard, Bhushan said two-thirds of the hospitalisations were in private hospitals and for tertiary care. “So we are taking care of problems like catastrophic expenditure,” Bhushan said. “We have spent Rs 8,000 crore, but the savings to people is Rs 15,000 crore.”
Bhushan, 58, is a former Indian Administrative Service officer, Rajasthan Cadre where he worked for nine years, before moving to the World Bank as a senior economist in 1994. He holds a doctorate in health economics and a masters in health sciences from Johns Hopkins University, USA apart from degrees from Indian Institute of Technology (IIT)-Banaras Hindu University and IIT Delhi. Before his current role, he served as Director General, East Asia, Asian Development Bank.
Edited excerpts from the interview:
How has the first year of PMJAY been? What has been working, and what has not?
In the first year, the momentum has been quite good and we are quite pleased with the way the scheme has rolled out. We have to expand it; there is huge disparity amongst the states, because some states have started the scheme for the first time. When you have to create an ecosystem to start a new scheme, it takes time. This is what is happening in Uttar Pradesh (UP) and Bihar. Also, these states have poorer infrastructure to provide services.
The portability feature has proved to be quite handy. [Portability allows patients seek healthcare in any empanelled hospital anywhere in the country]. For example, 10,000 people have gone outside UP to Uttarakhand--most of them to Rishikesh AIIMS [All India Institute of Medical Sciences]. Many people are going to Delhi. Similarly, Bihar is sending people outside because they don't have health infrastructure.
In terms of recipient states, Delhi is the national healthcare provider and Gujarat and Maharashtra are other recipients in bigger states.
[Since September 2019, 50,544 of the 6.8 million hospitalisations (0.7%) involved the use of the portability feature, according to figures shared by the NHA with IndiaSpend.]
We need to improve the performance of the scheme in the green-field states. We need to work on awareness generation and strengthen the supply of services in these states. For that we are working with NITI Aayog [the Centre’s policy think-tank] to understand how we can provide incentives for new hospitals to come out in these places. In some cases, for states which are far away like North-East and some of the islands like Andaman and Lakswadweep, we are working to provide transport cost to the mainland--because it is the major cost component in these places.
We are trying to improve awareness in general, as well as provision and quality of services. We are also trying to get more and more hospitals on board.
We have now also revised our packages. Earlier, some providers had indicated that rates were low and so we are working on that. Our aim is to get all the big hospitals to our scheme.
To ensure quality of services, we are working with the department of health research at ICMR [Indian Council of Medical Research] to develop standard treatment workflow. Our IT systems will ensure that those workflows are followed.
We are building some checks and balances--like in hip replacement, we are putting in place boards that will examine whether those procedures are required. We are also working on cancer care so that the right amount of treatment is given--not over or under treatment. If the person needs chemotherapy, radiation, or surgery, that should be decided by qualified treatment provider. Similarly in cardiovascular disease, we have a system where they could scrutinise whether the person needs a stent or if the hospital has prescribed a stent to earn money.
Next is the detection and prevention of fraud and abuse. For that we are strengthening our IT system and when we find some patterns [of malpractice and fraud], we come down heavily on that.
Every week we share with states, the potential fraud cases based on our analysis of the data. We are also finalising a company which will help us with forensic analysis and big data analysis and give us alerts that we can share with states. We are developing the capacity with the states so that they could do it themselves. Finally, we are improving our IT system and have come up with a tool called ‘Zero’, which will be more robust, more user-friendly, more secure and interoperable.
We provide those triggers, and many of the fraud cases have been detected. Till now, 300 hospitals have been suspended, we have claimed the money back and FIRs [first information reports] have been launched.
At an event in November 2019, Alok Kumar, senior advisor to Niti Aayog, spoke about a plan for health systems to cater to the middle class--which is currently not covered in any scheme. Are there any plans to broaden this pool of beneficiaries?
We are only one year old and right now we have to consolidate what we are doing before expanding. Our aim is to strengthen the ecosystem for providing services for health insurance.
Also, our database is very old. It is a 2011 database so we have to clean it up and exactly identify the people still left out and how to make them part of the scheme.
Once we have covered all the poor people, the call has to be taken by the government whether they want to expand and bring in [the middle class]. So the vision document that Mr Alok Kumar had shared recently shows the long-term vision. But when we go to them, we want to be sure that we have a system and an ecosystem ready.
Is the addition of new beneficiaries being done by the NHA or through various government departments?
We are not adding new beneficiaries, we are only identifying beneficiaries who have been left out. That call [of adding beneficiaries], the government has to take.
So is a list being enumerated?
I would not say enumerated, but we are looking at the group of people who are being left out.
For example, we are working with other ministries: Like the ministry of labour is prepared to pay for all the construction workers and bidi workers, so we will include them. Similarly, we are looking to include workers of micro, small and medium enterprises [MSMEs] in collaboration with the MSME ministry. We have also signed an MOU [memorandum of understanding] with the ESI [Employees’ State Insurance], and we are working with ESI to consolidate those workers.
You mentioned standard treatment workflow to be enforced for quality of care. Has there been any study to measure it?
We have not done a quality of care study but we have feedback from the beneficiaries. We call all the beneficiaries who have availed the services. More than 80% said they are satisfied with the services. Some very minor numbers are not happy and some said they were charged money for the services. We get the money refunded to them, lodge a complaint, and ask the state governments to review that.
Since PMJAY has the advantage of having a big pool, has it brought down the cost of medicines?
About the medicine cost, I don't know. In India, the medicine cost is quite low anyway.
Medicines comprise a bigger share of out of pocket expenditure. For example, 70% of household cost on health is on medicines.
Now, instead of the beneficiary paying of it, we are paying for that. But we have not conducted a study to show that the costs have come down but hopefully as the scheme becomes deeper, the cost will come down. Not only the cost of drugs and pharmaceuticals but also that of implants and devices should come down.
An October 2019 Federation of Indian Chambers of Commerce and Industry report said that the rates are not viable for private hospitals to make a profit or even survive and they are going through a slump.
We have revised the rate and we have taken into account all the inputs that we have received from various industry associations.
Do you have insights about how it has improved care in rural areas?
It's been only one year so we can't expect a huge change. We are seeing some development in that direction and many district hospitals are getting more money. They are improving their infrastructure, they are bridging the gap.
We are also seeing that many private players are planning to expand their operations in tier-2 and tier-3 cities which may help in further expansion.
Are the funds for the scheme enough? In 2019-20, Rs 6,500 crore was allocated to the scheme while it is estimated that Rs 10,000 crore is needed.
They are more than enough--since the uptake of the scheme was not that much. We had not used the entire amount, so I think money has never been a problem for this scheme.
What are the challenges that you foresee?
There are huge number of challenges: How to reach the last mile, how to ensure the quality of services, how to ensure that no frauds take place and how to ensure IT system continues to work and there are no glitches.
We work on all these every day. We get feedback that due to connectivity, the services are not available in some places. We need to respond to that. In general, we get the feedback that many poor people are being missed out. Those are always there.
This scheme takes care of tertiary care, but what about secondary and primary care because that is where more people are affected? Catastrophic expenditure is for tertiary care, but a lot of it is paid out of pocket at the secondary and primary level.
We are hoping that once we have very strong health and wellness centres, they will take care of much of the primary and secondary care. The government system has to be stronger to provide free drugs and diagnostics. For tertiary and for catastrophic expenditure, we have PMJAY services.
(Yadavar is a special correspondent with IndiaSpend/HealthCheck.)
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