Ranchi: On April 11, 2024, 42-year-old Rudolf Kujur arrived in Ranchi, 131 km from his village Bendora in Jharkhand’s Gumla district, with his day-old baby boy in one hand and a chatai (mat) in another. Two government hospitals in Gumla and Lohardaga said they were unable to handle post-birth complications and could not treat his child, who wasn’t feeding or passing stool, he says, and asked him to go to Ranchi for treatment. After moving from pillar to post in two private hospitals and a government medical college, his son passed away, laying bare the failures of the government health programme and the world’s largest health insurance scheme, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY).

The AB PM-JAY scheme was launched in 2018, with the aim of reducing people’s out-of-pocket expenditure on health, and to provide them with better healthcare. The scheme provides a health cover of Rs 5 lakh for a family per year for secondary and tertiary care hospitalisation, and asks for the establishment of 150,000 Health and Wellness Centres (HWCs) by transforming existing sub-centres and primary health centres. Its target was to bear the cost of hospitalisation of 107.4 million families from poor and marginalised sections, which was later expanded to cover 120 million families. .

Despite higher spending on the scheme year-on-year, experts say there is little regulation of the quality of care under the programme, as Kujur’s story shows. They add that the public healthcare system needs to improve as a whole before the programme can be successful.

As India votes in the last phase of the election, we report on the problems people face in accessing the AB PM-JAY, a flagship programme of the Bharatiya Janata Party-led government.

Poor public sector healthcare

The holes in the care of Kujur’s family started right from their village.

On March 16, 2024, Jyoti Ekka, Kujur’s wife, found out that the child in her womb was taking in toxins and excreta, endangering their life, in the ninth month of her pregnancy. She needed an immediate caesarean section (C-section) and was admitted to Sadar Hospital in Gumla, 31 km away from her home. There, she was told to go to Sadar Hospital in Lohardaga, over 75 km from her home, for the operation.

The doctor at Sadar Hospital in Lohardaga referred her baby boy to the Rajendra Institute of Medical Science (RIMS), a public hospital and medical college in Ranchi, 131 km from the family’s home. Ekka stayed back to take care of her other children and Kujur left for Ranchi.

Ekka had started visiting the anganwadi centre when she was four months pregnant. “Ideally, the Sahiya at the ANM (Auxiliary Nurse and midwife) centre should have liaised between Kujur’s family and the public health facility appropriate for the child’s condition, which would have saved him enormous amount of time and money,” says Taramani Sahu, who has worked on public healthcare issues, and closely works on food security with the NREGA Sangharsh Morcha in Jharkhand.

IndiaSpend has written to the Sadar Hospitals in Gumla and Lohardaga asking them whether they have facilities to take care of neonatal illnesses, and why they referred the baby to RIMS in such a critical state.

Rudolf Kujur at the Ranchi Institute of Medical Sciences, where his son was finally operated upon, after visiting three other hospitals.

While in the ambulance, RIMS authorities asked the child to be taken to a private hospital, Curesta Global, in Ormanjhi, 26 km from RIMS. It is unclear why RIMS would transfer the baby to a private facility, given that RIMS had the surgical facility. We made multiple attempts to reach out to the director of RIMS, Raj Kumar, also the CEO of the medical college, by phone. We have written to Kumar asking him why the child was transferred to a private hospital, and will update the story when he responds.

Private hospitals are reluctant to operate under AB-PMJAY

After public hospitals transferred the baby to private facilities, the family were dependent on government insurance through AB PM-JAY to cover any charges. Kujur, like many Adivasi families in Jharkhand, is dependent on his small farm and forest produce for survival, and did not have the funds required to treat his child.

Curesta Global took Kujur’s Ayushman card, but also asked him to deposit Rs 21,600, and admitted the child to the neonatal intensive care unit. While admitting the baby, the hospital noted that he was critical, and that treatment started through a nasal tube, the baby was given an inotrope for his heart and other supportive measures. Despite being in the hospital for four days, the child worsened, with his abdomen swelling. On April 14, Kajur says hospital authorities asked him to take the child to Rani hospital, a private hospital in Ranchi.

Hospitals are not supposed to charge patients who are treated under the government’s Ayushman Bharat insurance programme. But Rudolf Kujur says he was asked to pay when he admitted his son to the hospital. Pictured, the receipts of the payments he made to Curesta hospital.

Photo Credit: Sushmita

A representative at Curesta hospital, who refused to share their name and designation, said that the patient took a LAMA discharge (Leave Against Medical Advice). Kujur says he does not know what this means and that the hospital discharged the baby. The hospital representatives also said that they did not charge Kujur money, as he was registered under the AB PM-JAY Scheme.

Under the scheme, Rs 5 lakh covers various costs including medical examination, consultation and treatment, pre-hospitalisation, non-intensive and intensive care services, medicine and medical consumables, diagnostic and laboratory services, accommodation.

On April 15, Kujur reached Rani hospital, where they took his Ayushman card, provided a bed and put the baby on oxygen. The baby’s health kept deteriorating--he would still not take milk, could not pass stool, and was expelling black mucus from his mouth. Kujur says hospital authorities said they would be unable to treat the child there, and asked Kujur to take the child to another hospital

Rani hospital said that under the “PMJAY package, medical and surgical management can not be combined”, as per the discharge summary provided to the family. When IndiaSpend called Rani hospital to ask what happened, a representative said, “the patient had already availed medical facilities and under the Ayushman Bharat scheme, he or she could only avail either…at the time of admission we didn’t know that he will require surgical facilities”.

While medical facilities mean examination, diagnostics, testing etc., surgical facilities mean the medicines and equipment required for a surgery (for example a stent) as well the costs incurred in surgery. We verified with surgeons at Mumbai’s JJ Hospital if AB-PMJAY costs only cover one of the two. A surgeon, on condition of anonymity, informed that this was not the case. A hospital could simply discharge the patient from one department and re-admit them to another department. He also mentioned that private facilities usually resort to such tactics because their costs of surgery are too high.

Another government employee in a Maharashtra-based hospital, on the condition of anonymity, confirmed that the baby’s surgery would have been covered under AB-PMJAY, but that consumables for the baby's surgery alone could have cost up to Rs 1 lakh, a reason for private hospitals to turn down surgeries.

One of the reasons private hospitals are reluctant to do expensive surgeries is because of the delay in getting the reimbursement from the government. The Claims Adjudication Manual of the National Health Authority (NHA) for AB-PMJAY says that all claim payments (for both public and private-empanelled hospitals) should have a turnaround time of 15 days for intra-state claims and 30 days for inter-state claims.

But a 2023 analysis by the Delhi-based think-tank Centre for Policy Research (CPR) shows delays in payment of claims: 40% of claim payments took more than 45 days, while 16% took between 30 and 45 days.

In 2018, an article by CPR had argued that the fact of the scheme being oriented towards insurance, makes it more likely to suffer from either over or under treatment. They gave the example that health facilities could suggest a bypass where a stent could help the patient, as a bypass would be more expensive. On the other hand, if hospitals sense that there is not much profit, they may not enrol in the scheme at all or turn patients away.

“Many empaneled hospitals don’t want to continue with the scheme because they don’t get their remuneration easily. Any kind of public-private partnership will always have its limitations,” said Brinelle D’Souza, chairperson of the Centre for Health and Mental Work at the School of Social Work at the Tata Institute of Social Sciences (TISS).

Too late to save a life

“When we saw the child on April 19, he was wrapped in cloth that had turned black, he wasn’t even cleaned up till then,” says Sahu, the activist, who pushed for his urgent treatment at RIMS, when the family came back to that hospital on April 18.

The doctor at RIMS explained that the baby had intestinal perforation, caused by a condition called necrotizing enterocolitis (NEC), a life-threatening illness, almost exclusively affecting neonates, with a mortality rate of 50%. Its signs include poor feeding, vomiting, abdominal tenderness, all signs that Kujur’s son showed.

On April 28, the baby was operated upon, for a burst intestine. The doctor said that by the time the baby was operated upon, his condition was already very serious and he was critical. When this reporter visited, the doctor said that the baby was still under observation, and would open his eyes intermittently.

On April 30, in the early hours of the morning, he passed away.

When this reporter called the state health department to get clarifications on accountability measures to check such incidents, she was directed to Abu Imran, former district magistrate of Ramgarh and Sub-Divisional Officer (SDO) of Latehar. IndiaSpend has asked Imran the reason for this delay in the baby’s treatment, and the implementation of the AB PM-JAY programme in the district. We have also written to the state health department asking what they are doing to streamline these gaps. We will update this story when we receive a response.

Ayushman Bharat, by the numbers

In the 2024-25 budget, the Union government allocated Rs 7,500 crore for PM-JAY, an increase of over Rs 300 crore from 2023-24.

In 2018-19, only 50% of funds available were spent across India, as per a 2021-22 budget brief by CPR. In 2019-20, spending of funds available improved, with some states (Tamil Nadu and Meghalaya) spending all of the allocated funds, the brief shows.

Source: Centre for Policy Research

In 2023, a Comptroller General Audit report pointed out some other major problems with the AB PM-JAY scheme, including inadequate validation leading to crores of expenditure on ineligible beneficiaries.

The AB PM-JAY scheme was preceded by the Rashtriya Swasthya Bima Yojana (RSBY). Experts told IndiaSpend that for AB PM-JAY’s success, the reasons for the failure of RSBY should be carefully studied. For example, a study in West Bengal reported that the households did not prefer RSBY-empanelled hospitals, the distribution of the empanelled hospitals was uneven and that there was a clear urban bias in the empanelment.

As per data from the 75th round of the National Sample Survey, 42.5% of ailments are treated in private clinics, and 23% in private hospitals. An analysis by PRS legislative research institute, a Delhi-based research organisation, found that people were pushed to private health facilities because of the poor quality of public healthcare.

A 2013 paper argued, and experts concurred, that for a universal insurance scheme to be successful, there has to be equitable distribution of healthcare. But this is not true for AB PM-JAY, as the list of empanelled hospitals shows.

The 2023 CAG report found that there was low availability of empanelled healthcare providers per 100,000 beneficiaries in several states such as Madhya Pradesh (2.7) Assam (3.4), Dadra Nagar Haveli-Daman Diu (3.6), Maharashtra (3), Rajasthan (3.8) and Uttar Pradesh (5).

As of 8 a.m. on May 24, 2024, 29,105 hospitals across the country were empanelled with AB-PMJAY, but as many as 22,528 had been inactive since the last six months, the government dashboard for the programme says. About 6,500 have been inactive since they were empaneled. Of the empanelled hospitals, nearly 57% are public hospitals. The programme has authorised approximately 65 million hospital admissions, worth Rs 81,979 crore.

A 2021 study in three states, conducted by the National Health Authority, found that only 9.8% of beneficiaries in Bihar, 12.4% in Haryana and 59% in Tamil Nadu were aware of the scheme. The authors wrote that the government’s Information, Education and Communication activities to increase awareness and knowledge of AB PM-JAY haven’t reached beneficiaries.

If empaneled hospitals are far, it reduces the willingness of people to go for treatment for that hospital. In an essay, Sheetal Ranganathan, a life sciences and healthcare expert, wrote that a majority of Indians, especially the rural areas, don’t report sickness unless rendered inactive to work and earn, either by injury or the flare up of a chronic condition. Going to a health centre for minor treatments implies missing a day’s wage, a condition many in the rural parts of India can’t afford.

“The issue in rural areas is the lack of basic healthcare facilities itself because the scheme is tied to empaneled hospitals,” says D’Souza of TISS. In addition, she said, “the people who are really vulnerable, like homeless, trans persons or sex workers, are completely left out of the scheme.

“What should have been done actually is to strengthen the public health system and make it more accessible and helping [reduce] out-of-pocket expenditure,” D’Souza said.

In addition, the epidemiological profile of the ailments covered under AB PM-JAY misses a large section of the population that has heart conditions and other chronic ailments that are not covered by the scheme, says Ranganathan, who is also a faculty member at Mumbai-based think tank Observer Research Foundation. “The scheme is overwhelmingly missing the voices of the people it intends to cater to.”

A lot needs to be done

In March 2024, the government reportedly formed a panel to review the effectiveness of the scheme and issue findings within 45 days. Such a report is not publicly available. We have written to Mansukh Mandaviya, Union Minister for Health and Family Welfare, and will update the story when we get a response.

On April 14, 2024, while releasing Bharatiya Janata Party’s Sankalp Patra (manifesto) for the 2024 Lok Sabha elections, at its headquarters in New Delhi, Prime Minister Narendra Modi said that every individual under 70 years of age will be brought under the scheme.

D’Souza says, “I would say that as an idea this is [the scheme] a step towards universalisation of healthcare, but the scheme has not been accessible to people and the grand ideas aren’t translating.”

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